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Full text of "The American journal of the medical sciences"

Property of the 

Lancaster City and County 
Medical Society 



No 



* 



THE 



AMERICAN IOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS | MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION J OF THE AMERICAN PHILOSOPHICAL SOCIETY j OF THE 
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 
&C. &C. &C. 



NEW SERIES. 
vol. xyi. 




PHILADELPHIA: 
LEA & BLANCHARD. 

LONDON: 
WILEY & PUTNAM, AND JOHN MILLER. 



1848. 



69442 



i 



Entered according to Act of Congress, in the year 1848, by 
LEA AND BLANCHARD, 
in the Clerk's Office of the District Court of the Eastern District of Pennsylvania, 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



v. 16 
Med.. 



TO READERS AND CORRESPONDENTS, 



The gentlemen to whom we entrusted the task of reviewing Dr. Stille's 
Elements of General Pathology, and the late Dr. McClellan ; s Principles and Prac- 
tice of Surgery, have disappointed us; and we are compelled to postpone the Re- 
views of these works until our next number. 

The following works have been received :— 

On Bandaging and other Operations of Minor Surgery. By F. W. Sargent, M. D. 
Phila., Lea & BTanchard, 1848. (From the Publishers.) 

Manuals on the Blood and Urine. By John William Griffith, M.D., F.L.S., 
&c, G. Owen Rees, M. D., F. R. S., F. G. S., &c, and Alfred Markwick, M. D. ; 
&c, in one volume. Philada., Lea & Blanchard, 1848. (From the Publishers.) 

Practical Observations on certain Diseases of the Chest, and on the Principles 
of Auscultation. By Peyton Blackiston, M. D., F. R. S., &c. &c. &c. Philada., 
Lea & Blanchard, 1848. (From the Publishers.) 

Elements of Natural Philosophy; being an experimental Introduction to the 
Study of the Physical Sciences. By Golding Bird, A. M., M. D., F. R. S., F. L. S. ; 
&c. &c. &c, with 372 illustrations. From the revised and enlarged third London 
edition. Philada., Lea & Blanchard, 1848. (From the Publishers.) 

A Dispensatory and Therapeutical Remembrancer; comprising the entire Lists 
of Materia Medica, Preparations and Compounds, with a Brief and Distinct Ver- 
sion of every Practical Formula, as authorized by the London Edinburgh and 
Dublin Royal College of Physicians, in the latest Editions of their Several Phar- 
macopoeias; to which are subjoined copious relative tables, exemplifying approved 
forms under which compatible Medicines, &c, may be extemporaneously com- 
bined, &c. &c. &c. By John Mayne, M. D., L. R. C. S., Edinburgh. Revised with 
the addition of the Formula of the United States Pharmacopoeia, &c. By R. Egles- 
feld Griffith, M. D., author of Medical Botany, &c. Phila., Lea & Blanchard ; 
1848. (From the Publishers.) 

The Principles of Mechanics, of Machinery and Engineering. By Julius 
Weisbach, Prof, of Mechanics and Applied Mathematics in the Royal Academy 
of Freiburg. First American Edition. Edited by W. R. Johnson, A.M., Civ. and 
Min. Eng. In two Volumes. Illustrated with 1000 engravings on wood. Vol. I. 
Theoretical Mechanics. Philadelphia, Lea & Blanchard, 1848. (From the Pub- 
lishers.) 

Elements of General Pathology: a Practical Treatise on the Causes, Forms, 
Symptoms, and Results of Disease. By Alfred Stille, M.D., Lecturer on Pa- 
thology and the Practice of Medicine, &c. &c. &c. Phila., Lindsay & Blakiston, 
1848. (From the Author.) 

Chemical Technology; or Chemistry applied to the Arts and to Manufactures, 
By Dr. F. Knapp, Prof, at the University of Giessen. Translated and Edited, with 
numerous notes and additions, by Dr. "Edmund Ronalds, Lecturer on Chemistry, 
at the Middlesex Hospital, and Dr. Thomas Richardson of Newcastle-on-Tyne. 
First American edition with notes and additions by Prof. W. R. Johnson. Vol. I. 
Illustrated with 214 engravings on wood. Phila., Lea & Blanchard; 1848. (From 
the Publishers.) 

Lectures on the Theory and Practice of Physic. By John Bell, M. D., &c, and 
Wm. Stokes, M. D., &c. Fourth edition, revised and enlarged. Two vols. 8vo. 
Phila., Edward Barrington & George D. Haswell, 1848. 

Lettres sur la Lithotritie ou Fart de Broyer la Piere. Par le Docteur Civiale. 
Sixieme lettre. Paris, 1848. (From the Author.) 

Annuaire de la Mortalite Genevoise, publie sur Pinvitation du conseil de sante. 



-i 



TO READERS AND CORRESPONDENTS. 



Par le Docteur Marc cVEspine, Membre du Conseil de Sante, &c. &c. Troisieme 
publication. Annees 1844 et 1845. Geneve, 1847. (From the Author.) 

Memoire surles Retrecissements organiques de l'Uretre, etsur Pemploi de nou- 
veaux instrumens de Scarification et d'Tncision, pour obtenir la cure radicale de 
cette maladie, suivi d'un appendice sur le traitement des retrecissements par la 
Malaxation ; par Martial Dupierris, D M. et C. Nouvelle edition. Paris, 
Germer Bailliere, 1847. (From Dr. John B. Beck.) 

Proceedings of the Annual Convention of the Connecticut Medical Society, May 
J 848, together with a list of Members and the Annual Address. Hartford, 1848. 
(From Dr. Russel.) 

Notes on the Theory of Human Existence, comprising remarks on Vitality, the 
Mind, and incidentally the Soul. The whole being an exposition of the Nature, 
Powers and Destiny of Man. By Thomas L. Wright, M. D. Cincinnati, 1848. 
(From the Author.) 

The Physiological Effects of Alcoholic Drinks, from the British and Foreign 
Medical Review of Dr. Forbes; with Documents and Records of the Massachusetts 
Temperance Society, illustrating the origin of the Temperance Reformation, and 
its progress in the State of Massachusetts. Boston, 1848. (From Dr. J. C.War- 
ren.) 

Address delivered before the Alabama State Medical Association at its first re- 
gular session at Selma, March 9th, 1848. By H. V. Wooten, M. D. Published 
by the Association. Montgomery, Ala., 1848. (From the Author.) 

The Reciprocal Relations of Physicians and Clergymen: a Speech delivered at 
t^e Anniversary Dinner of the "New York Society for the relief of Widows and 
Orphans of Medical Men," on Wednesday, Nov. 17th, 1847. By the Rev. John 
M'Krebs, D.D. Published by the Stewards. New York, 1847. 

Lectures on Yellow Fever, its Causes, Pathology, and Treatment. By John 
Hastings, M. D., U. S. Navy. Phila., Lindsay and Blakiston, 1848. (From the 
Publishers.) 

Ether and Chloroform: a Compendium of their History and Discovery. By Henry 
J. Bigelow, M. D., one of the Surgeons of the Mass. Gen. Hospital. Boston, 1848. 
(From the Author.) 

Report of the Chicago Retreat for the Insane. By Edward Mead, M.'D., Su- 
perintendent. Chicago, 1848. (From the Author.) 

State of the Accounts of the Pennsylvania Hospital for the year ending, fourth 
month, 22d, 1848, as adjusted by the Managers, and laid before the Contributors 
at their Annual Meeting, fifth month, 1st, 1848. Philada., 1848. 

Fifth Annual Report of the Mount Hope Institution near Baltimore, for the year 
1847. By Wm, H. Stokes, M. D. Baltimore, 1848. 

Transactions of the Belmont Medical Society for 1847. Published by the 
Society. St. Clairsville, Ohio, 1848. 

A case of Typhus or Ship Fever, with Remarks. By William Ingalls, M. D., 
&c. &c. Boston, 1848. 

Remarks on Deodorization and Disinfection, and on Sir William Burnett's Dis- 
infecting Fluid, the Solution of the Chloride of Zinc. By F. Stratton, M. D., 
Surgeon Royal Navy, Particular Service. Montreal, 1848. (From the Author.) 

Address delivered before the State Agricultural Society, Members of the Legis- 
lature, and of the Medical Seciety of the State of New York, at the Capitol in 
Albany, Feb. 1848, on the Food of Plants. By Alex. H. Stevens, M. D. ; &c. &c. 
Albany, 1848. (From the Author.) 

Valedictory Address to the Graduating Class of the Medical Department of 
Pennsylvania College, March 7th, 1848. By William R. Grant, M. D., Prof, of 
Anaiorny and Physiology. Published by request of the Class. Philada., 1848. 
(From the Author.) 

An Introductory address delivered before the Medical Class of the Med. School 
of Maine, March 13th, 1848. By Edmund R. Peaslee, A.M., M. D. ; Prof, of 



TO READERS AND CORRESPONDENTS. 



5 



Anatomy and Surgery. Published by the Class. Brunswick, 1848. (From the 
Author.) 

Annual Address read before the Northern Medical Association of Philadelphia, 
January 6th, 1848. By Arnold Naudain, iYI. D. Philadelphia, 1848. (From the 
Author.) 

An Address delivered before the Society of Alumni, of the Medical Department 
of Hampden Sidney College. By Chas. P. Johnson, M. D. Published by order 
of the Society. Richmond, 1848. (From the Author.) 

Nineteenth Annual Report of the Inspectors of the Eastern State Penitentiary of 
Pennsylvania. Philada., 1848. (From Dr. Robert A. Given.) 

By-Laws, adopted by the Managers of the New Jersey State Lunatic Asylum, 
at Trenton, also the Act to provide for the Organization of said Asylum, and for 
the care and maintenance of the Insane; passed March 23d, 1847 : and the sup- 
plement to the same act passed March 9th, 1848. Trenton, 1848. (From Dr. H. 
A. Buttolph, Superintendent and Physician ) 

Annual Catalogue of the Medical Department of the University of the State of 
Missouri, (session of 1847-48,) and circular for the ensuing session, with an Ad- 
dress of Dr. Samuel Cartwright, delivered before the class, and published by their 
request. St. Louis, 1848. (From the Faculty.) 

Catalogue of the Second Session of the Memphis Medical College. Session, 
1847-48. Memphis, Term., 1848. 

Catalogue of Medical Graduates in the Univ. of Penn., at the commencement 
held April 8th, 1848. 

University of New York Medical Department. Annual announcement of Lec- 
tures. Session of 1848-49. New York, 1848. 

A Lecture Introductory to a Course of the Institutes of Medicine and Materia 
Medica, for Session of 1847-48. By Martyn Paine, A. M., M. D., Professor of 
Inst, of Medicine and Materia Medica, &c. &c. &c. New York, 1847. (From 
the Author.) 

Lecture Introductory to a Course on Obstetrics and the Diseases of Women and 
Children, delivered April 10, 1848. By Wm. Harris, M. D. Philadelphia, 1848. 
(From the Author.) 

A Defence of Dr. Charles T. Jackson's claims to the Discovery of Etherization. 
Containing Testimony disproving the Claims set up in favour of Mr. W. T. C. 
Morton, in the Report of the Trustees of the Massachusetts General Hospital, and 
in No. 20 1 of Litf ell's Living Age. By Joseph L. Lord and Henry E. Lord. Boston, 
' 1848. (From Dr. C. T. Jackson.) 

The Ether Controversy. Vindication of the Hospital Report of 1848. By N. J. 
Bowditch. Boston, 1848. (From the Author.) 

The following Journals have been received in exchange : — 

Revue Medico-Chirurgicale de Paris; sous la Direction deM. Malgaigne M.D. 
P. Feb., March, April,~1848. 

Monthly Journal and Retrospect of the Medical Sciences. April, May, 1848. 

Provincial Med. and Surg. Journ. Edited by R. J. N. Streeten, M. D., F. L. S. 
Foreign Editor, W. H. Ranking, M. D. March, April, May, 1848. 

The Edinburgh Medical and Surgical Journal. April, 1848. 

British and Foreign Medico-Chirnrgical Review, or Quarterly Journal of Pract. 
Medicine and Surgery. April, 1848. 

The London Medical Gazette. April, May, June, 1848. 

The Dublin Medical Press. April, May, June, 1848. 

The British American Journal of Medical and Physical Science. Edited by 
Archibald Hall, M. D., &c. &c. &c. April, May, June, 1848. 

Southern Medical and Surgical Journal. Edited by Paul F. Eve, M. D. April, 
May, June, 1848. 

1* 



6 



TO READERS AND CORRESPONDENTS. 



The Med. Examiner and Record of Med. Science. Edited by R. M. Huston. 
M. D. April, May. June, 1848. 

The Western Journal of Medicine and Surgery. Edited by Drs. D. Drake, L. P. 
Yandell and T. W. Colescott. April, May, June, 1848. 

The Western Lancet and Hospital Reporter. Edited by Drs. L. M. Lawson and 
J. P. Harrison. April, May, June, 1848. 

The American Journ. of Pharmacy, published by authority of the Philadelphia 
College of Pharmacy. Edited by Joseph Carson, M. D., assisted by a publishing 
committee. April, 1848. 

The Missouri Med. and Surgical Journal. Edited by T. Barbour, M. D., and 
A. J. Coons, M. D. April, May, June, 1848. 

The Charleston Medical Journal and Review. Edited by Drs. P. C. Gaillard, 
and H. W. De Saussure. May, 1848. 

The American Journal of Science and the Arts. Conducted by Professors B> 
Silliman, and B. Silliman, Jr., and James D. Dana. May, 1848. 

The New Orleans Medical and Surgical Journal. Edited by Drs. J. Harrison, 
W. M. Carpenter, and A. Hester. May, 1848. 

The Buffalo Medical Journal and Monthly Review of Med. and Surg. Science- 
Edited by Austin Flint, M. D. April, May, June, 1848. 

The New York Journal of Medicine and the Collateral Sciences. Edited by 
Charles A. Lee, M.D. May, 1848. 

The Illinois Medical and Surgical Journal. Edited by Drs. Blaney. Brainard. 
Herrick, and Evans, Profs, in Rush Medical College. Feb., March, 1848. 

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D., and 
Wm. M. McPheeters, M. D.~ March, April, 1848. 

The New Jersey Medical Reporter and Transactions of the New Jersey Medical 
Society. Edited by Joseph Parrish. April, 1848. 

The American Journal of Insanity. Edited by the Officers of the New York 
State Lunatic Asylum, Utica. April, 1848. 

The American Journal and Library of Dental Science. Edited by Dr. C. A. 
Harris, A. Westcott, and W. H. Dwinelle, Esq. April, 1848. 

The Annalist; a record of Practical Medicine in the city of New York. Edited 
by Wm. C. Roberts, M.D. April, May, 1848. 

The North Western Med. and Surgical Journal. Edited by Dr. W. B. Herrick 
and John Evans. April, May, 1848. 

Communications intended for publication, and Books for Review, should be sent./m 
of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, Lon- 
don; or to Wiley & Putnam, New York: or W. D. Ticknor, Boston; or M. Hector Bos- 
sange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Lea & Blanchard. 

The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



CONTENTS 



OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES 

NO. XXXI. NEW SERIES. 

JULY, 1848. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Vital Statistics of Philadelphia, for the decennial period from 1830 to 1840. 

By Gouverneur Emerson, M. D. - - - - - - 13 

II. Statistics of Amputations in the New York Hospital, from January 1st, 
1839, to January 1st, 1848. By Henry W. Buel, M. D., Resident Surgeon. 33 

III. Thoughts and Observations on Congestive Fever. By Charles E. Laven- 
der, M. D., of Selma, Alabama. - - - - - - 43 

IV. Further Observations on Trismus Nascentium, with Cases illustrating its 
Etiology and Treatment. By J. Marion Sims, M. D., of Montgomery, Ala. 59 

V. On the Causes operative in determining the Proportions of the Sexes at 
Birth. By Gouverneur Emerson, M. D. - - - - 78 

VI. Excision of the Cervix Uteri for Carcinomatous Disease. By Washing- 
ton L. Atlee, M.D., Professor of Medical Chemistry in the Medical Depart- 
ment of Pennsylvania College, Philadelphia. - - - - 86 

VII. Dissection of a Fungus Haematodes Oculi. By W. Clay Wallace, M. D., 
New York. --------- 94 

VIII. Occlusion and Rigidity of the Os Uteri and Vagina. By James D. 
Trask, M. D., Whiteplains, Westchester Co., New York. - - - 95 

IX. Operation for Artificial Anus. By J. Mason Warre^, M. D., one of the 
Surgeons to the Massachusetts General Hospital. - - - 116 

X. Poisoning by Arsenic successfully treated with Calcined Magnesia. By 
Emory Bissel, M. D. ; of Norwalk, Conn. - - - - -121. 

REVIEW. 

XI. Practical Observations on Midwifery, and the Diseases incident to the 
Puerperal State. By Alfred H. McClintock, M. D., F.R.C.S.I., Ex-assistant 
of the Dublin Lying-in Hospital ; Vice-President of the Dublin Obstetric 
Society; and Lecturer on Midwifery and the Diseases of Women and Chil- 
dren in the School of Medicine, Park St. : and Samuel L. Hardy, M. D., 
F.R.C.S.I., Ex-assistant of the Dublin Lying-in Hospital, and Vice-president 
of the Dublin Obstetric Society. " Multum restat adhuc operis, multum- 
que restabit; nec ulli nato post mille ssecula preecludetur occasio aliquid 
adhuc adjiciendi." — Seneca. Dublin, 1848 : 8vo., pp. 368. - - 123 

BIBLIOGRAPHICAL NOTICES. 

XII. Principles of Medicine : comprising General Pathology and Therapeu- 
tics, and a biief general view of Etiology, Nosology, Semeiology, Diagno- 



8 



CONTENTS. 



sis, Prognosis, and Hygienics. By Charles J. B. Williams, M. D., F. E. S., 
Professor of the Principles and Practice of Medicine, and of Clinical Medi- 
cine, and First Physician to the Hospital, University College, London, &c. 
&c. Second Edition, considerably enlarged. London, 1848: 8vo. pp. 533. 144 

XIII. Lectures on Yellow Fever; its Causes, Pathology, and Treatment. By 
John Hastings, M. D., United States Navy. 8vo. pp. 69. Philadelphia: 
Lindsay & Blakiston, 1848. - - - - - - 163 

XIV. 1. Thirtieth Annual Report of the Physician and Superintendent of the 
McLean Asylum for the Insane. Boston : 1848. 

2. Twenty -fourth Annual Report of the Physician and Superintendent of the 
Retreat for the Insane. Hartford: 1848. 

3. Thirty-first Annual Report of the State of the Asylum for the relief of Per- 
sons deprived of the use of their Reason. Philadelphia: 1848. 

4. Twentieth Annual Report of the Physician and Superintendent of the 
Western Asylum. Richmond, Va. : 1848. 

5. Annual Report of the Superintendent of the Kentucky Lunatic Asylum. 
1848. 

6. Reports of the Physician, and the Superintendent and Resident Physician 

of the Lunatic Asylum. Columbia, South Carolina : 1847. - - 166 

XV. Practical Observations on Certain Diseases of the Chest, and on the Prin- 
ciples of Auscultation. By Peyton Blakiston, M. D., F. R. S. ; Fellow of 
the Royal College of Physicians ; Physician of the Birmingham General 
Hospital, and formerly Fellow of Emanuel College, Cambridge. 8vo. pp. 
384. Philadelphia : Lea & Blanchard. " - - - - -171 

XVI. On the Blood and Urine. By John William Griffith, M. D., F.L.S., 
&c. G. Owen Rees, M. D., F.R.S., F.G.S., &c, and Alfred Mark wick, 
M D., &c. In one volume— pp. 182, 165, 113-460. Philadelphia: Lea & 
Blanchard, 1848. ........ 172 

XVII. Anniversary Discourse before the New York Academy of Medicine. 
November 10th, 1847. By John W. Francis, M. D. Published by order 

of the Academy. New York : 1847. Svo. pp. 112. - - - 174 

XVIII. A Dispensatory and Therapeutical Remembrancer, comprising the 
entire lists of Materia Medica, Preparations and Compounds, with a full 
and distinct version of every Practical Formula as authorized by the Lon- 
don, Edinburgh and Dublin Royal Colleges of Physicians in the latest edi- 
tions of their several Pharmacopoeias ; to which are subjoined copious 
relative Tables exemplifying approved forms under which compatible 
medicines, &c, may be extemporaneously combined, &c. &c. By John 
Mayne, M. D., L. R.C.S., Edinburgh. Revised, with the addition of the 
Formulae of the U. S. Pharmacopoeia, by R. Eglesfeld Griffith, M. D., &c. 
Lea & Blanchard: Philadelphia, 1848. 1 vol. 12mo. p. 329. - - 179 

XIX. The Dublin Dis*ctor; or, System of Practical Anatomy. By Robert 
Harrison, M. D., M. R. I. A., &c. &c, Professor of Anatomy and Surgery in 
the University of Dublin. Fifth edition, Dublin and New York, 1847. 2 
vols. 12mo. pp. 915. - - - - - - - 180 

XX. The Young Stethoscopist ; or, The Student's Aid to Auscultation. By 
Henry I. Bowditch, M. D., one of the physicians of Mass. Gen. Hospital. 
Second Edition. New York : S". S. & W. Wood, 1848. 12mo. pp. 304. 180 

XXI. On Bandaging and other Operations of Minor Surgery. By F. W. Sar- 
gent, M. D. Philadelphia: Lea & Blanchard, 1848: pp. 379. Small 8vo. 180 

XXII. — Elements of Natural Philosophy ; being an Experimental Introduc- 
tion to the Study of the Physical Sciences. By Golding Bird, A.M., M.D., 
F.R.S., F.L.S., Fellow of the Royal College of Physicians; late President 
of the Westminster Medical Society ; Corresponding Member of the Phi- 
losophical Institute of Basle, of the Philosophical Society of St. Andrews, of 
the Medical Society of Hamburgh, etc. ; Assistant Physician to, and Pro- 
fessor of Materia Medica at Guy's Hospital. With three hundred and 
seventy-two Illustrations. From the revised and enlarged third London 
edition. Philadelphia : Lea & Blanchard, 1848. - - - - 181 

XXIII. — Principles of the Mechanics of Machinery and Engineering. By 
Julius Weisbach, Professor of Mechanics and Applied Mathematics in the 



CONTENTS. 



9 



Royal Mining Academy of Freiburg. First American Edition. Edited by 
Walter R. Johnson. A. M., Civ. and Min. Eng. Formerly Professor of 
Mechanics and Natural Philosophy, &c. &c. In two volumes. Illustrated 
with one thousand engravings on wood. Philadelphia: Lea & Blanchard, 
1848. 8vo., 408 pp. Chemical Technology; or, Chemistry Applied to 
the Arts and to Manufactures. By Dr. F. Knapp, Professor at the Uni- 
versity of Giessen. Translated and Edited, with numerous Notes and 
Additions. By Dr. Edmund Ronalds, Lecturer on Chemistry at the Mid- 
dlesex Hospital, and Dr. Thomas Richardson, of Newcastle-omTyne. First 
American Edition, with Notes and Additions. By Professor Walter R. 
Johnson, of Philadelphia. Volume I. Illustrated with two hundred and 
fourteen engravings on Wood. Philadelphia: Lea & Blanchard, 1848. 
8vo. 504 pp. 182 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



On the Channels by which Urea 
is eliminated after the extirpation 
of the Kidneys. By MM. Ber- 
nard and Barreswil. - 
On the Effects of the Introduction 
of Common Salt directly into the 



183 



PAGE 

Stomach. By M. Bardeleben. 183 
Non-absorption of Narcotic Poi- 
sons. By Mr. E. W. Day. - 183 
Lymphatics of the Lungs. By 
Dr. Jarjavay. - - - - 185 



Organic Chemistry. 



Oxalate of Lime a Constituent of 
the Simplest Cellular Plants and 
of the Secretion of the Mucous 
Membranes. By Dr. C. Schmidt. 
On the V ariations in the Amount 



185 



of the Phosphatic Salts in the 
Urine in Health and Disease. By 
Dr. Bence Jones. - - - 186 
Urea in Normal Sweat. By Dr. 
Landerer. 187 



Materia Medica and Pharmacy. 



8. Proteine as a Medical Agent. By 

E. W. Tusson. - - - - 187 

9. Aqueous Solution of Opium, aci- 
dulated with Muriatic Acid. By 

Dr. J. G. Nichol. - - - 187 



10. Iodized Oil. By M. Marchal. 

11. Tartrate of Potassa and Iron. 
By M. Mialhe. - 

12. External Employment of Bella- 
donna. By Mr. Donovan. 



187 



188 



10 



CONTENTS. 



Medical Pathology and Therapeutics and Practical Medicine 



page 

13. Treatment of Phthisis Pulmo- 
nalis by Cod Liver Oil. By Dr. 
Hughes Bennett. - - 189 

14. Case of very extensive Gelati- 
niform Cancer of the Peritoneum, 
involving the Lymphatic Glands 
of the Abdomen and Ovaries, and 
simulating Ascites. By Edward 
Ballard, M. D. - - - - 189 

15. Pathological Nature of Bright's 
Disease. By Dr. W. T. Gairdner. 190 

16. On Certain Pathological Condi- 
tions of the Blood and Urine in 
Gout, Rheumatism, and Bright's 
Disease. By Alfred B. Garrod, 
M.D. - - - - - 192 

17. On Albuminuria independent of 
Renal Disease. By Dr. Finger. 194 

18. On Ozone as a Cause of Disease. 

By Prof. Schonbein. - - - 195 

19. Therapeutic Action of Cod Liver 
Oil. By Dr. Hughes Bennett. - 196 



PAGE 

20. Quinine in Intermittent Fever. 

By M. Bouchardat. - - - 197 

21. Double Pneumonia, — Hepati- 
zation of the Posterior Portions of 
the Lower and Middle Lobes of 
both Lungs, — Recovery. By W. 

H. Ranking, M. D. - - - 198 

22. On the Nature, Cause, and Pre- 
vention of Scurvy. By A. B. Gar- 
rod, M. D. - 200 

23. Tubercle and Cancer. By Dr. 
Rogneita. 203 

24. Free Communication between 
the Ventricles without Cyanosis. 

By Dr. Hare. - - - - 203 

25. Erysipelas of the Hairy Scalp. 

By M. Grisolle. - - - 203 

26. Condition of the Gums in Phthi- 
sis. By Dr. Frederiq. - - 204 

27. Laryngitis. By Mr. Parr. - 204 

28. Steracutine. By Dr. Verga An- 
drea. 206 



Surgery. 



29. Cases of Femoral and Popliteal 
Aneurism successfully treated by 
Compression. By Dr. Bellingham. 206 

30. Oblique Fracture of the Femur 
immediately above the Condyles. 

By Mr. James Spence. - - 212 

31. Case of Compound Fracture of 
the External Condyle of the Fe- 
mur, laying open the Knee-joint, 
complicated with a simple Trans- 
verse Fracture of the Lower 
Third of the same Bone. By W. 

P. Brookes. - - - - 214 

32. Fracture of the Olecranon — new 
method of bringing the fragments 
into apposition. By M. Hervez 

de Chegoin. - - - - 214 

33. Cases of Ununited Fracture suc- 
cessfully treated. By W.B.Page. 
Esq. - - - - - 215 

34. Diagnosis of Incomplete Frac- 
tures. ByM. Debron. - -216 

35. On Petit's Operation for the Re- 



lief of Strangulated Hernia. By 
James Luke, Esq. - 216 

36. Operation for Strangulated Um- 
bilical Hernia. By G. B. Childs, 
Esq. - - - - - 218 

37. On the operation of Gastrotomy 
as applicable to cases of obstructed 
(Esophagus. By Prof. Sedillot. 218 

38. On the Treatment of Strictures 
of the (Esophagus by Catheterism 
and Cauterization. By M. Gen- 
dron. - - - - , - 220 

39. Fractured Patella. Subsequent 
Laceration of the Soft Parts, im- 
plicating the Joint. By Dr. Cro- 
ker King. 220 

40. Catheterism. By Mr. W. N. 
Sprong. - - - - 222 

41 Tracheotomy in Tetanus. By 
Dr. Hughes. - - - - 222 

42. Death from Air entering a Vein 
divided whilst inserting a Seton 
in the Neck. - - - - 222 



Ophthalmology. 



43. Painful Affection of the Eye 
cuied by the Extraction of a 
Tooih. By Dr. Emmerich. - 222 



44. The Eye naturally adapted for 
Distant Vision. By Volkmann 
and Hueck. - - - - 222 



CONTENTS. 



11 



Midwifery. 



page 



45. Disorders of the Nervous Sys- 
tem during Pregnancy. By Dr. 
Lever. - 

46. Inflammation and Abscesses of 
the Uterine Appendages, (Ova- 
ries, Fallopian Tubes, and Cellu- 
lar Tissue.) By Dr. Henry Bennett. 

47. Post-Puerperal Metritis. By 
MM. Chomel and Willemin. - 



223 



223 



224 



48. Vomiting in Pregnancy. By 

M. Trousseau. - - - - 225 

49. Intra-uterine Peritonitis in the 
Fcetus. By Dr. Simpson. - - 225 

50. Case of Double Cephalhemato- 
ma. By Prof. Simpson. - - 225 

51. Maternal and Infantile Mortal- 
ity in the Dublin Lying-in Hospi- 
tal. By Dr. Clay. - - - 226 



Anesthetic Agents. 



52. Varieties of Anaesthesia, &c. By 

M. Beau. 227 

53. Physiological Action of Chloro- 
form. By M. Amussat. - - 227 

54. Narcotism from Inhalation of 
Vapours. By Dr. Snow. - - 230 

55. Action of Chloroform on the 
System. By Francis Sibson, Esq. 230 

56. Mode of Administering Chloro- 
form. By Prof. Simpson. - - 232 

57. Notes on the Anaesthetic Effects 
of Hydrocarbon, Nitrate of Ethyle, 
Benzin, Aldehyde, and Bisulphu- 
ret of Carbon. By J. Y. Simpson, 
M.D. 232 

58. Reckless Employment of Chlo- 
roform in a case of Delirium Tre- 
mens. - - - - 234 



59. Use of Chloroform in Tetanus 
By Mr. R. L. Baker. - 

60. Chloroform in Neuralgia. By 
Mr. Sibson. - 

61. Chloroform in Dysmenorrhea. 
By Dr. J. Henry Bennett. - 

62. Chloroform in Midwifery Prac- 
tice. By Dr. Nevins. 

63. Injurious Effects of Chloroform. 
By Dr. Nevins. - 

64. Injurious Effects of Chloroform 
in Midwifery Practice. By Dr. 
Reed. - - - - ' - 

65. Violent Convulsive Movements 
caused by Chloroform adminis- 
tered to a Patient in Labour. By 
Mr. Kay. - 



- 235 



235 



235 



- 236 



- 236 



239 



239 



Medical Jurisprudence and Toxicology. 



66. Life Insurance. - 

67. On the Existence of Several 
Metals in the Human Blood. By 
Mr. E. Millon. - - 

68. Progress of Putrefaction, &c. - 

69. On Transparent and Opake Ar- 
senious Acid. By M. Bussy. 

70. Test for Strychnine. By M. 
Marchand. - 

71. Proof of Poisoning. 



239 



239 
241 

241 

242 
242 



72. Poisoning by Bichloride of Mer- 
cury. 243 

73. Remarkable Case of Suicide. 

By Prof. Fenger. - - - 244 

74. Appearance of the Areola as a 
Sign of Pregnancy. By Dr. Simp- 
son. - - 244 

75. Simulated (Edema of the Left 
Arm. - - - - - 244 



76. The Influenza which prevailed 
in London in 1847-48. By Dr. 
Webster. ----- 245 



Miscellaneous. 

77. Revaccinations in the Russian 
army in 1847. - - - - 245 



AMERICAN INTELLIGENCE. 
Original Communications. 



Case of Prolonged Gestation in 
which the date of the Conception 
was accurately ascertained. By 
R. H. Mcllvain, M. D. - - 247 



The Smart-weed as a Remedy for 
Mercurial Salivation and Aph- 
thous Stomatitis, (Communicated 
in a Letter to the Editor.) By 



12 



CONTENTS. 



R. Wilcox. - - - - 247 
Case of Wesley Pine, the murderer 
of Mrs. Russell. By W. P. Gib- 
bons, M. D. - - - - 248 
On Antiscorbutic Diet. By Isaac G. 
Porter, M. D. - - - - 249 



PAGE 

Kreosote in Erysipelas. By P. 
Fahnestock, M.D. - - - 251 

Proceedings of the Third Meeting 
of the Association of Medical Su- 
perintendents of American Insti- 
tutions for the Insane. - - 252 



Domestic Summary. 



Popliteal Aneurism successfully 

treated by Compression. By Dr. 

J. Knight. - - - - - 
False Aneurism with Obliteration 

probably congenital of the Aorta. 

By Dr. West. - 
Case in which a Corpus Luteum in 

Process of Formation, was found 

coinciding with Menstruation. By 

Dr. Middleton Michel. 
Fracture of the Neck of the Femur 

within the Capsule-— bony union. 

By Dr. N. W. Condit. 
Spina Bifida treated by Injection of 

the Tincture of Iodine. By Prof. 

D. Brainard. - 
Foreign Body in the Trachea — 

Tracheotomy—Cure. By Wm. 



255 



257 



260 



261 



262 



Davidson. - 

Expulsion of two Foetuses of une- 
qual size at the same time. By 
Dr. Elias Horlbeck. - 

Abnormal Distribution of the Thy- 
roid Arteries. By Prof. James 
Blake. - 

Iodide of Potassium, a Cure for 
Nurses 1 Sore Mouth. By Dr. H. 
D. Holt. 

Geranium Maculatum a Cure for 
Mercurial Salivation. By Dr. G. 
Maclean. - - - 

Case of Chronic Tetanus success- 
fully treated by Ether Inhalation. 
By Dr. Isaac Parrish. 

American Medical Association. 

University of Pennsylvania. - 



263 



263 



- 264 



265 



- 265 



265 
265 
266 



THE 



AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY, 1848. 



Art. I. — Vital Statistics of Philadelphia, for the decennial period from 
1830 to 1840. By Gotjverneur Emerson, M. D. 

Various causes operating extensively upon the destinies of the human 
race, could never be recognized, unless viewed in their effects upon large 
masses. The presence of malign influences would often escape notice, 
nor could the extent of the evils produced by them, ever be accurately 
ascertained, without the aid of statistical investigations. It is frequently 
objected against these, that so many erroneous items are included in the 
data. But the effectual answer to such objections is, that in the multitude 
of observations, the errors existing here and there, are neutralized and lost 
in the great mass of facts accumulated. 

In the numbers of this Journal for November 1827, and November 1831, 
we presented estimates of the mortality, and other interesting matters 
relating to the changes of, the population of Philadelphia, during a period 
of twenty-four years. We now embrace within our calculations an addi- 
tional period of ten years, bringing the subject up to the last general census 
of 1840. This, with our former estimates, includes a period of no less than 
thirty-four years, and exhibits the vital statistics of Philadelphia and the 
changes of its population with the mortality from each particular disease, 
at various ages for that period. 

General Population. — The total population of the city of Philadelphia, 
and adjoining Corporations and Districts making returns of interments 
to the Board of Health, was, in 1840, according to the census of the gene- 
ral government made in that year, 226,693 — an increase of 57,255 within 
the previous ten years. 

Of the entire population, 105,792 were males, and 120,901 females. 
No. XXXI.— July, 1848. 2 



14 



Emerson on the Vital Statistics of Philadelphia. 



[July 



TABLE A. 

White Population of the City of Philadelphia and adjoining Districts, from which returns of 
Interments are made. From the United States Census of 1840. 



WHITE MALES. 





Under 

5 

years. 


o yrs. 

and 
under 

10 


10 to 
15 


15 to 
20 


20 to 
30 


1 

30 to 40 to 
40 | 50 


50 to 
60 


60 to 
70 


70 to 
80 


80 to 
90 


90 to 
100 


100 
and up- 
wards. 


Total. 


City 


56G7 


4027 


3423 


4128 


8963 


5582 


3025 


1390 


741 


290 


74 






37328 


Kensington 


2190 


I486 


1101 


955 


2023 


1611 


896 


383 


164 


62 


10 




| 11 
i 6 


10881 


N. Liberties 


2591 


1934 


1459 


1682 


3463 


2260! 


1291 


692 


274 


96 


18 


7 


15778 


Unincorporated 




























N. Liberties 


295 


203 


185 


185 


326 


250 


121 


81 


33 


12 


2 


2 




1659 


Spring Garden 


20S9 


1600 


1192 


1414 


2731 


1752 ! 


872 


432 


168 


43 


14 


3 




12315 


Penn Township 


245 


219 


164 


162 


332 


278 


137 


65 


44 


10 


3 






1659 


Southwark 


2190 


1508 


1197 


1180 


2578 


1907: 


1038 


485 


204 


81 


18 


3 


1 


12390 


Passyunk 


154 


9S 


116 


90 


154 


104 j 


63 


38 


22 


3 


5 






847 


Moyamensing 


1053 


649 


451 


427 


963 


854 


487 


252 


101 


26 


9 


2 




5275 


Total white males 16474 


11729 


9288 


10223 


21 53i 


14593 


7930 


331S 


1751 


628 


153 


1 24 


19 


98168 


WHITE FEMALES. 





Under 






























5 


5 to 


10 to 


15 to 


20 to 


30 to 


10 to 


50 to 


60 to 


70 to 


80 to 


90 to 


100 to 


Total. 




years. 


10 


15 


20 


30 


40 


50 


60 


70 


80 


90 


100 


110 


City 


5566 


4279 


4221 


56G0 


11724 


6425 


3700 


2206 


1292 


570 


171 


15 


1 


45830 


Kensington 


2041 


1406 


1103 


1014 


263 


146C 


S62 


468 


250 


118 


27 


4 




9021 


N. Liberties 


2625 


1910 


1670 


2131 


3901 


2266 


1451 


932 


433 


268 


78 


13 


1 


17688 


Unincorporated 






























N. Liberties 


239 


206 


196 


148 


333 


198 


114 


73 


39 


22 








1573 


Spring Garden 


2037 


1621 


1472 


1356 


3312 


1836 


1014 


590 


273 


115 


•33 


8 




14169 


Penn Township 


283 


209 


164 


162 


311 


212 


86 


70 


34 


20 


5 




1 


1557 


Southwark 


2164 


1556 


1293 


1535 


3045 


1771 


1165 


714 


437 


175 


47 


6 


1 


13909 


Passyunk 


131 


100 






160 




44 


24 


14 


IS 








724 


Moyamensing 


1011 


643 


533 


580 


1172 


S08 


389 


257 


122 


63 


15 


5 


2 


5600 


Total white females 


16100 


11930 


10736 


13163 


24231 


15054 


8825 


5334 


2894 


1369 


376 


51 


6 


110069 


White males 


16474 


11729 


923? 


10223 


21533 


14598 


7930 


3818 


1751 


628 


153 


24 


19 


98168 


Total white males 






























and females 


32574 


23659 


20024 


23386 45764 


29652 


16755 


9152 


4645 


1997 


629 


75 


25 


208237 



White Population. — The table in our present series, marked A, exhi- 
bits the numbers of the white inhabitants at thirteen periods of life. Of 
the sum total, 208,237, the males constituted 98,168, whilst the females 
amounted to 110,089. This shows a total increase of 55,088, of which 
sum 24,621 were males, and 30,447 females. 

The numbers of white males and females, compared at the different ages 
designated, stand thus : 





Under Be- j 10 
5 tween and 
years 5 & 10, 15 


15 

and 

20 


20 
and 
30 


30 
and 
40 


40 
and 
50 


50 
and 
60 


60 
and 
70 


70 
and 
80 


SO 
and 
90 


90 
and 
100 


100 
and 
up- 
wards 


Males 
Females 


16.474 11.729 9,233 
16,100 11,930 10,736 


10,223 
13,163 


21.533 
24:231 


14.598 
15,054 


7.93(1 
8,825 


3,818 
5,334 


1.751 

2,894 


628 
1,369 


153 
37G 


24 
51 


19 
6 


Excess of 
females 


j 201 ! 1,448 


2,940 


2,698 


456 


895 


1,516 


1,143 


741 


223 


27 





Under the first and last periods only, do the males exceed the females, 
whilst in all the others, the female preponderance is very great, especially 
after the 10th year. 



1848.] Emerson on the Vital Statistics of Philadelphia. 15 



The respective proportions of the white males and females, at the several 
periods of life designated in the table, are as follows : 



Of and under 5 years, the males exceed the females 


2.27 per cent. 


Between 5 and 10 years the 


females exceed the males 


1.68 


(C 


" 10 and 15 




a 




1350 


« 


« 15 and 20 








22.38 


(C 


" 20 and 30 




cc 


u 


11.13 




K 30 and 40 




CC 




3.03 


u 


« 40 and 50 




ce 




10.14 




" 50 and 60 


cc 




u 


28.42 


cc 


" 60 and 70 








39.49 


u 


" 70 and 80 






cc 


54.12 




« 80 and 90 






CC 


59.30 




" 90 and 100 




(( 


u 


52.94 


It 



" 100 years and over the males exceed the females 68.42 " 
It thus appears that the excess of males at birth, usually about 7 per 
cent., has disappeared before the 10th year, at which period an enumeration 
of the sexes living, between 5 and 10 years of age, exhibits a female pre- 
ponderance of 1.68 per cent. By the 15th year, the female excess has 
attained about I3| per cent., and at the next period of life, including the 
years between 15 and 20, the female preponderance has actually reached 
22.38 per cent. It now declines, so that between the 20th and 30th years, 
the females exceed the males only 11.13 per cent., whilst between the 
30th and 40th years, the female excess has declined to 3.03 per cent. 
Now, however, it again begins to increase, and this goes on pretty steadily 
through the other ages designated, until, passing the centenary period, the 
male preponderance, among the few left, returns as at birth. 

It is interesting to compare these results with others obtained from the 
previous census, and to mark the general correspondence and occasional 
striking differences existing between the proportions of males and females 
at the different periods of life, in the two decennial periods. 

The following statement will show the general concurrence and particu- 
lar differences. 







1830. 


1840. 




Of and under 5 years, male excess 




2\ per cent 


Between 5 and 10 


years " 


If 




cc 


" 5 and 10 


years, female excess 




H 


cc 


" 10 and 15 




8 


m 




« 15 and 20 




7 


22£ 




" 20 and 30 


cc cc 


10 


11 




« 30 and 40 




7 


3 


cc 


" 40 and 50 


U CC 


9 


10 


■ cc 


« 50 and 60 


cc (( 


25 • 


28 


cc 


" 60 and 70 




37 


39i 


cc 


" 70 and 80 


cc cc 


48 


54 




" 80 and 90 




44 


59 




" 90 and 100 « " 


28 


53 


cc 



16 Emerson on the Vital Statistics of Philadelphia. L^uty 



TABLE B. 

Coloured Population of the City of Philadelphia and adjoining Districts, from which returns 
of Interments have been made. From the Census of 1840. 



m 


COLOURED MALES. 












Under 








55 to 


100 






10 


10 to 24 


24 to 36 


3fi tn 


inn 


and up- 


JL Oldi 


■ 


years 










wards 




city ; . . 


940 


1029 


1130 


696 


188 


3 


3986 


Kensington ... 


71 


45 


26 


47 


11 




200 


Northern Liberties . - . 


132 


93 


103 


67 


31 




426 


Unincorporated N. Liberties . 


3 


12 


12 


9 


2 




38 


Spring Garden 


107 


187 


205 


133 


31 


2 


665 


Penn Township 


17 


14 


15 


9 


3 




58 


Southwark .... 


153 


121 


122 


118 


46 


3 


563 


Passyunk .... 


2 


6 


5 


3 


1 




17 


Moyamensing 


427 


409 


421 


309 


104 


1 


1671 


Total coloured males 


1852 


1916 


2039 


1391 


417 


9 


7624 


COLOURED FEMALES. 




Under 








55 to 


100 






10 


10 to 24 


24 to 36 


36 to 55 


100 


and up- 


Total 




years. 










wards 




City ..... 


1124 


1901 


1921 


1156 


414 


: 7 


6523 


Kensington .... 


54 


55 


54 


30 


19 




212 


Northern Liberties . 


122 


168 


174 


81 


37 




582 


Unincorporated N. Liberties . 




11 


6 


6 


3 




26 


Spring Garden 


111 


226 


204 


119 


42 




702 


Penn Township 


18 


13 


15 


18 


4 




68 


Southwark .... 


154 


184 


155 


141 


52 




686 


Passyunk .... 


2 


1 


2 




1 




6 


Moyamensing . . 


400 


598 


569 


334 


125 


1 


2027 


Total coloured females . 


1985 


3157 


3100 


1885 


697 


8 


10,832 


Total coloured males 


1852 


1916 


2039 


1391 


417 


9 


7,624 


Total coloured males and females 


3837 


5073 


5139 


3276 


1114 


17 


18,456 



Coloured Population. — This is exhibited in Table B, drawn from the 
United Slates census of 1840. It constitutes about 7.8 per cent, of the 
total population. The whole amount is 18,456, of which 7,624 are males 
and 10,832 females. The increase within the decennial period is 3,812, 
or about 20 per cent., a ratio of about 2$ per cent, per annum. This, it 
will be observed, is much below the rate of multiplication in the white- 
population, where it is about 3£ per cent. 

The different periods of life designated in the census of the blacks are 
only six, and the disparity subsisting between the proportions of the sexes 
at each of these is very remarkable, differing greatly from the proportions 
among the whites alone, as will sufficiently appear by a comparison of the 
following statements with those previously given. 



1848.] Emerson on the Vital Statistics of Philadelphia. 



17 



Estimate of the Proportions of Coloured Males and Females. 





All of and 


Between 


24 


36 


55 


100 




under 10 yrs. 


10 and 


and 


and 


and 


and 




24 yrs. 


36 


55 


100 


upwards. 


Males 


1852 


1916 


2039 


1391 


417 


9 ' 


Females - 


1985 


3157 


3100 


1885 


697 


8 


Female excess - 


133 


1241 


1061 


494 


280 





Thus, at the 10th year, the females exceeded the males about 

In 1840. In 1830. 



Between the 10th and 24th years 
" " 24th and 36th years 
" " 36th and 55th years 
" " 55th and 100th years 



6J per cent. 
39 « 
34 « 
26 " 
41 



5^ per cent. 
38 « 
27 " 
14 " 
27 « 



The great disparity between the sexes among the coloured population 
in the city of Philadelphia, and which appears to have greatly increased, 
especially in the more advanced ages, I have formerly attempted to account 
for by ascribing it to the more frequent demand for the services of females 
than exists in the country, together with the greater mortality among the 
males. Of those, however, who reach the extreme duration of life, the 
males predominate, as we have observed to be the case with the white cen- 
tenarians. 

Births. — In our last series of statistical investigations, published in 
this Journal for November, 1831, we gave the births for each year of the 
preceding decennial period. We are now enabled to add ten years more, 
making in all twenty-one consecutive years, since the record of births was 
commenced in Philadelphia. Table C exhibits the births in each year of 
the last decennial period, from 1831 to 1840, inclusive, with the respective 
proportions of the sexes, totals, and excess of males over the females at 
birth. 

According to the returns made to the Health Office from the various 
practitioners of midwifery whose names are registered, the grand total of 
births within the city of Philadelphia and adjoining corporations during the 
ten years, was 76,536. Of this number 39,512 were males, and 37,024 
females, being an excess of males over the females of 6.29 per cent., a 
ratio rather lower than that furnished by former periods. The cause of 
this diminution in the excess of male children may probably be referred 
to the operation of unusual circumstances within the period, which will be 
the subject of further investigation. 



18 



Emerson on the Vital Statistics of Philadelphia. [July 



TABLE C. — Births per annum in Philadelphia, from 1831 to 1840 inclusive, with the 
respective proportions of the Sexes. 



Year. 


Males. 


Females. 


Totals. 


Excess of 
male births. 


1831 


3787 


3555 


7342 


232 


1832 


3834 


3419 


7253~ 


415 


1 oqo 
looo 


3S40 


3802 


7642 


38 


1834 


3937 


3635 


7572 


302 


1835 


4041 


3815 


7856 


226 


1836 


3864 


3544 


7408 


320 


1837 


4235 


3953 


8188 


282 


1838 


3982 


3798 


7780 


184 


1839 


3769 


3493 


7262 


276 


1840 


4223 


4010 


8233 


213 


Totals 


39,512 


~~ 37,024 


76,536 





Mortality .—In addition to the ordinary causes of mortality, Philadelphia 
has, within the decennial period from 1830 to 1840, been twice visited by 
a pestilential disease, unknown in the previous history of the country. 
The total mortality during the ten years, from all causes, amounts to 
49,678. 

The proportion of deaths to the total population, will be seen by refer- 
ring to Table D. It has varied, with each year, from 1 in 28 to 1 in 49. 

The greatest mortality was in 1832, the first year of the malignant cho- 
lera, of which disease the deaths reported amount to 1,021, the whole from 
all sources being 6,425. The average annual mortality, compared to the 
general population, is about one death in 41 inhabitants. 



TABLE D. — Exhibiting the deaths in the city of Philadelphia and adjoining districts in each 
year from 1830 to 1840 inclusive, with the proportions to the general population, and also 
those of the white and coloured populations separately (still born excluded). 



Year. 


Mortality of whites 
alone. 


Mortality of the 
1 colored population. 


Total population. 

1 


Col'd population. 


J General mortality, 
still-born excluded. 


General mortality 
to total population. 


Proportion of deaths 
among the whites 
alone. 


Death of blacks 
alone. 


1831 


4197 


446 


174,541 


14,985 


4623 


1 in 37.89 


1 in 


39.60 


1 in 33.60 


1832 


5754 


678 


179,694 


15,336 


6425 




28.21 


« 


28.83 


" 22.65 


1833 


3625 


450 


185,000 


15,876 


4128 


cc 


45.36 




47.32 


« 35.28 


1834 


4281 


488 


190,461 


16,285 


4765 


cc 


40.69 


cc 


41.46 


« 33.37 


1835 


4793 


534 


196,084 


16,667 


5358 




37 39 




38.32 


« 31.21 


1836 


4340 


697 


201,974 


17,057 


5022 




41.25 




43.80 


" 24.47 


1837 


4356 


533 


207,834 


17,456 


4881 


l 11 


43.89 




45.16 


« 30.75 


1838 


4525 


611 


213,970 


17,865 


5118 




43.27 


cc 


45.00 


« 29.23 


1839 


4258 


549 


220,287 


18,293 


4765 


(C 


48.08 




49.48 


" 31.30 


1840 


4176 


477 


226,693 


18,456 


4593 


cc 


49.37 




52.28 


" 38.68 












Averages, 


41.15 


43.12 


31.05 



1848.] 



Emerson on the Vital Statistics of Philadelphia. 



19 



The following shows the mortality in Philadelphia, in 1840, compared 
with the population at different periods of life, as represented by the United 
States census for that year. 

Under Between Between Between Between 100 yrs. 
10th yr. 10 and 20. 20 and 30. 30 and 50. 50 and 100. and upwards. 

Total Pop. 60.070 48,473 50,903 49,683 17,612 42 

Mortality 2,227 195 496 873 795 7 

By this statement, it appears that, in 1840, when the census was taken 
by the general government, the mortality under the 10th year, compared 
with the population of and under that age, was 3-7 per cent., or 1 death to 
about 27 of the population at the age designated. The deaths between 10 
and 20, were only 1 in about 260 of the inhabitants of that period of life ! 
Those between the 20th and 30th years of age, were 1 in about 102; be- 
tween the 30th and 50th years, 1 in about 57; between the 50th and 100th 
years, 1 in 22; whilst those of and over 100, were 1 in 6 of the inhabit- 
ants. 

It is proper to observe, that, in estimating the proportions of inhabitants 
at particular ages, some difficulty exists in consequence of the whites and 
blacks being enumerated in the census at different ages. Up to the 10th 
year, the respective proportions are correctly given; but after that age, 
the column in our statement representing the population between 10 
and 20, contains the coloured from 10 to 24, the column of 20 to 30, con- 
tains the coloured from 24 to 36, that from 30 to 50, contains the coloured 
from 36 to 55, and that from 50 to 100, contains the coloured from 55 to 
100. As the coloured population constitutes so small a proportion, this 
irregularity cannot materially affect the results of our calculations. 

White Population. — Taking the white inhabitants separately, the ave- 
rage mortality was 1 in 43, the lowest having been 1 in about 29, in 1832, 
and the highest 1 in 52, in 1840. Notwithstanding the ravages made by 
two visitations of malignant cholera, the average mortality has been consi- 
derably lower than for the preceding decennial period, when it was 1 death 
in 38*85 of the general population. 

Coloured Population. — The proportional mortality among the coloured 
population is given in Table C. Though still considerably more than that 
of the whites, it is much less than during the past decennial periods. The 
general average for the 10 years, from 1830 to 1840, was 1 in 31 — -the 
greatest proportion having been in 1832, the first year of the malignant 
cholera, when the deaths were about 1 in 22£ of the coloured inhabitants) 
— the highest in 1840, when the average was about 1 in 38|. This is 
strongly and most favourably contrasted with the results of the preceding 
decennial period, when the average was about 1 in 21, or double the rate 
of mortality of the whites. 



20 Emerson on the Vital Statistics of Philadelphia. [July 

It will thus be seen, that even the increased mortality occasioned by 
the visitation of an awful pestilence, falls far short of what has occurred 
at previous periods. In the years 1821 to 1826, inclusive, the annual 
deaths of the coloured population of Philadelphia, averaged 1 to every 
19-8 inhabitants, and during three years of the period, 1 in 15, 1 in 16, 
and 1 in 17, of the coloured population were swept off.* At present, in- 
stead of being double that of the whites, the average ratio of mortality be- 
tween 1830 and 1840, is 1 in 31 of the coloured inhabitants, that of the 
whites being 1 in 43. A very great amelioration in the condition of the 
coloured population is thus shown to have taken place. 

Particular Causes of Mortality. — -The particular diseases, and other 
causes, producing the mortality in Philadelphia during the decennial pe- 
riod from 1831 to 1840 inclusive, are designated in Table F. The ar- 
rangement is in accordance with the plan of a nomenclature and classifica- 
tion recommended for general adoption by the American Medical Associa- 
tion. 

It will be observed, that occasionally no deaths are set down in the co- 
lumns appropriated to some of the causes embraced in this plan. But it 
is not to be inferred that none occurred from such sources, since they have 
doubtless been included under other heads in the bills of mortality. Thus, 
in the 5th class, there are no deaths recorded from pericarditis, which is well 
known to be a disease frequently fatal. The deaths from it have probably 
been arranged, in the general bill, under some other head, or, rather, heads, 
such as inflammation of the heart, or pleura, or breast, or lungs. 

A hiatus of several years will be found in Class 4th, under the head of 
pleurisy, the deaths from which have undoubtedly been reported under 
other names, either as pneumonia, bronchitis, or some other acute inflam- 
mation of the chest. It is to be hoped that more accuracy may, in future, 
characterize the certificates of physicians, as well as the annual statements 
made by the Board of Health. 



See this Journal for November, 1827. 



1848.] Emerson on the Vital Statistics of Philadelphia. 21 

TABLE E. — Particular Diseases and sources of mortality in Philadelphia, during ten years } 
showing the amount for each year, 1831 to 1840 inclusive. 



I. ZIMOTIC, EPIDEMIC, ENDEMIC, AND CONTAGIOUS. 





| 1. Cholera. 


2. Cholera Infantum. 


j 3. Croup. 


j 4. Diarrhoea. 


5. Dysentery. 


| 6. Erysipelas. 


j 7. Fever, Intermittent. 


8. Fever Remittent. 


9. Fever, Typhus. 


10. Hooping Cough. 


d 
<a 


to 
_o 

C3 

CD 

ct 


13. Scarlatina. 


| 14. Small Pox. 


15. Syphilis. 


16. Thrush. 


1631 


18 


302 


127 


81 


121 


16 


15 


93 


92 


67 


24 


23 


200 


18 


4 


6 


1832 


1021 


366 


110 


172 


78 


21 


15 


94 


210 


58 


41 


118 


307 


43 


8 


6 


1833 


9 


197 


95 


87 


44 


17 


7 


SO 


84 


53 




1 


61 


168 


7 


9 


1S34 


204 


377 


81 


123 


70 


20 


3 


58 


61 


48 


3 




83 


212 


9 


8 


1S35 


27 


275 


123 


129 


114 


15 


3 


66 


42 


106 




248 


305 


106 


3 


9 


1536 


11 


212 


115 


136 


95 


24 


13 


85 


220 


94 




4 


240 


56 




9 


1837 


24 


243 


104 


100 


119 


20 


5 


57 


107 


40 




49 


205! 81 


5 


13 


1833 


13 


3S2 


101 


144 


141 


22 


3 


63 


70 


27 




123 


134 


45 


3 


13 


1S39 


21 


230 


83 


136 


120 


19 


1 


47 


47 


191 




3 


225 


5 


14 




1840 


23 


160 




119 


118 


7 


8 


39 


63 


4 




2 


244 


63 


7 






1371 


2769 


1023 


1227 


L02(J 


181 


73 


689 


996 


658 


68 


578 


2004 


827 


67 


73 





















II. DISEASES OF UNCERTAIN SEAT. SPORADIC DISEASES. 





Abscess. 


Atrophy. 


Cancer. 


Debility. 


Dropsy. 


Gout. 


Hemorrhage. 


Infantile Diseases. 


Inflammations. 


Malformations. 


o 

c 

a 


Scrofula. 


Sudden Deaths. 


Tumors. 




£^ 


ad 


03 


o" 

o* 


O} 


ci 

Ci 






Ct 


Ci 


i> 

C) 


% 


gi 


© 

CO 


1831 


21 


29 


19 


293 


367 


7 


33 




780 




24 


23 


79 


8 


1332 


19 


81 


23 


259 


366 


3 


30 




842 




22 


25 


52 




1S33 


21 


108 


95 


189 


302 


3 


26 




641 


S 


20 


12 


23 


1 


1834 


12 


96 


35 


207 


353 


1 


34 




731 


12 


24 




21 


2 


1835 


30 


112 


31 


175 


360 


4 


40 




886 


15 


35 


26 


19 


2 


1536 


23 


98 


28 


194 


317 




30 




817 


10 


30 


19 


19 




1837 


21 


116 


27 


165 


347 


1 


22 




859 


12 


28 


24 






1838 


29 


152 


41 


160 


332 


3 


25 




883 


17 


39 


27 






1839 


7 


149 


38 


125 


357 


3 


23 . 




888 


10 


12 


18 




6 


1840 


23 


125 


46 


142 


293 


4 


40 




846 


8 


16 


22 




1 




206 


1066 




388 


1912 3394 


36 


308 




8237 


92 


250 ,218 


213 


20 



III. OF THE NERVOUS SYSTEM. 





o 


Cephalitis. 


Chorea. 


Convulsions. 


Delirium Tremens. 


Epilepsy. 


Hydrocephalus. 


Insanity. 


Paralysis. 


Tetanus. 


Brain, Diseases of. 




CO 


§3 


co 
co 


CO 


is 

CO 


CO 

co 


& 


00 
CO 


§ 






1831 


60 


89 


1 


277 


110 


12 


203 


25 


59 


2 




1832 




102 


1 


342 


150 


7 


187 


14 


47 


3 




1833 


55 


72 





266 


123 


15 


170 


6 


40 





IS 


1834 


76 


104 


1 


250 


90 


12 


198 


4 


46 


9 


27 


1835 


71 


106 


2 


351 


62 


13 


214 


13 


42 


10 


38 


1836 


33 


96 


1 


283 


90 


s 


162 


19 


45 


7 


63 


1837 


57 


108 


2 


298 


66 


9 


192 


8 


37 


4 


86 


1838 


74 


150 


1 


302 


62 


11 


195 


3 


50 


5 


45 


1839 


59 


111 




300 


35 


13 


193 


6 


51 


4 


107 


1840 


86 


157 





2S6 


38 


8 


145 


6 


54 


7 


86 




704 


1095 


10 


2985 


826 


108 


1864 


104 


471 


51 


470 



22 



Emerson on the Vital Statistics of Philadelphia. 



[July 



IT. ORGAN'S OF RESPIRATION". 





3 
c 

< 


Bronchitis. 


Consumption. 


Hydrothorax. 


•2 
To 

ci 
h3 


Pleurisy. 


Pneumonia. 


Quinsy. 


Organs, &c., 
)iseases of. 


S 

.s 

3 
< 


03 

o 


53. Organs, &c., 
Diseases of. 












CO 


tj< 


CO 




. !— 1 

© 
if? 




ci 
m 




6 


63 


673 


48 




24 


192 






4 






1832 


11 


97 


631 


62 




19 


225 






3 






1333 


8 


37 


650 


52 


3 


8 


166 






5 






1834 


10 


121 


630 


52 




11 


169 






4 






1835 


12 


171 


717 


57 






240 






4 






1836 


10 


141 


755 


47 


3 




205 






2 






1837 


5 


146 


74- 


53 


5 




226 






2 






1838 


13 


118 


725 


57 






230 






4 






1839 


9 


143 


708 


67 


4 




228 












1840 


9 


112 




44 


4 


14 


211 






3 








593 


1 1 59 


7070 


39 


19 


76 


2092 






38 







V. ORGANS OF 
CIRCULATION. 













VI. OF 


THE DIGESTIVE ORGANS. 














« 
'o 

03 

< 


6 

~o 
O 


.2 

"to 
C 
O) 

c. 

ft 


0} 
CO 

H 


so 


.2 

CO 


.2 ' 

o 

CD 
3 

CO 

to 
=5 


to 

3 

o 


ti) 
a> 


5 

3 
o 


1 


Organs, &c., Dis- 
eases of. 


Pancreas, Disease 
of. 


to 

■s 

a 

CD • 

EC 


«5 
o 

■3 
5 

CS 


liiver, Disease of. 


Spleen, Disease of. | 




uo 




CO 

LO 




CO 
lO 


OS 


© 




o 


CO 
CO 




3 


CO 
CO 


CO 


CO ■ 
CO 


CO 


o 


1331 
1832 
1831 
1S34 
1835 
1S36 
1837 
1838 
1839 
1840 


27 
19 
22 
26 


4 
13 

8 
5 
6 
3 
3 
2 
8 
7 


4 
7 
1 

1 

5 
3 

2 
2 


81 
125 
135 
111 

96 
103 
111 
113 
175 
110 


34 
41 
43 
41 
30 
39 
34 
43 
35 
41 


14 
7 
4 
6 
4 
6 
5 
2 
2 
2 


5 
1 
2 
2 
3 
4 

2 


23 

17 

25 
24 
25 
18 
24 


8 
14 

9 
10 
12 
14 
10 

19 
5 




8 
12 

6 
9 
6 
9 
4 

6 






42 
21 
18 
37 
23 
17 
26 
21 
30 
25 


13 
6 
13 
10 
12 
18 
13 
13 
9 
12 


1 

10 


2 
1 
1 
1 




94 


59 


1 25 


1165 


1336 


52 


19 


156 


103 




67 






260 


119 


11 


5 





VI r. OF THE 




VIII. 


ORGANS 


IX. ORGANS 


X. OF THE 


INTEGU- 


URINARY 


ORGANS. 


OF 


GENERATION. 


OF 


LOCOMOTION. 


MENTARX SXSTEM. 




a 


to 


cd 
> 




•gans, &c, Dis- 
sases of. 


'£ 


rerperal Fever. 


.2 

S 

3 


p 

to to 
? w 
bo rt 


1 

s 
s 

3 


s 

M o 

oT ^ 
.3 


o 

CD 

to 

s 

£ 


c*4 
O 

4> 

cd 

-J! 
P 

of 


3 


5 

CD 


3 

3 
D. 
3 


cm, Disease of. 




P 


Q 


O 




o J 


o 




Ph 


o° 




O CO 


K 










cV2 








CO 




lO 






co 




© 

CO 


CO 


CO 


CO 


CO 


vi 

CO 


c€ 


J> 

CO 


1-31 
1832 
1833 
1834 
1835 
1836 
1837 
1336 
1839 
1840 


I 
1 


2 
3 
2 

2 


4 
1 
1 

6 

3 
3 
5 
2 
5 


3 

1 
1 


2 
1 
2 
3 
1 

4 
1 

2 
5 




9 
5 
6 
5 
10 

2 
8 
4 
7 


14 

8 
32 
19 
10 
13 
6 
6 
9 
17 






4 

5 
9 

12 
17 
4 
2 
10 
4 
6 




3 
2 
4 
3 

3 
2 
7 
3 


2 
3 
10 
10 
7 


1 
1 

1 


13 
11 

6 

18 

1 
i! 

7 

6 


l 

1 

4 
2 
3 
4 








37 


5 


21 




63 


134 










27 


17 


. 3 


107 


IS 





1848.] 



Emerson on the Vital Statistics of Philadelphia. 



23 



XT. OS" EXTERNAL CAUSES. 





88. Old Age. 


89. .Burns and Scalds. 


90. Drowned. 


91. Executed. 


92. Frozen. 


93. Glanders. 


94, Heat. 


| 95. Hydrophobia. 


! 96. Intemperance. 


97. Killed accident- 
ally* 


98. Killed by design. 


99. Lightning. 


100. Malpractice. 


101. Necusia. 


102. Poisoned. 


103. Strangulated. 


j 104. Starved. 


1831 


74 


25 


51 








2 




27 






1 






2 






1832 


58 


21 


55 












5 




2 








3 




2 


1833 


68 


30 


55 








1 


2 


18 




5 








3 




4 


1834 


61 


27 


60 




2 




16 


1 


23 




2 








1 




2 


1835 


71 


33 


61 




4 








19 




2 












18 


1836 


72 


24 


49 




8 








26 




3 








14 




5 


1837 


97 


24 


65 


1 


1 








24 












18 




10 


1838 


115 


25 


53 





4 




26 


2 


37 












7 




12 


1839 


97 


26 


39 


1 


6 




2 




34 












2 




19 


1840 


115 


21 


59 




4 




3 




35 




3 


2 







8 




26 




S23 


261 


547 


2 


29 




50 


5 


243 




17 


3 


1 


58 




93 



3S T OT CLASSIFIED. 




Suicide. 


Wounds. 


Still-born. 


Angina Pectoris. 


j Asphyxia. 


x: 
o 
S 

s 
< 


j Anemia. 


Anthrax. 


j Casualties. 


1831 
1832 
1833 
1834 
1835 
1836 
1837 
1833 
1839 
1840 


*2 
5 

18 

9 

16 

14 

8 
14 


4 

9 
1 

3 


316 
274 
312 
303 
303 
335 
32 L 
344 
343 
356 


1 
1 

2 
3 
6 
6 
2 


12 
5 
8 
14 
16 
15 
11 
21 
26 


1 
1 
1 

2 


4 
2 
1 
1 


1 

2 


20 
20 
21 
24 
21 
41 
85 
23 
27 
43 




115 


33 


3222 


23 


128 


5 


8 


3 


314 













CAUSES OF DEATH 


3TOT 


CLASSIFIED. 
















2 

© 
o 
O 


to 

o 


3 2 
o — 

o 


"5 

Is 
o 


.2 

OS 

fc£i 

5 
Q 


'to 
O 

>> 

o 


Coup de so- 
leil. 


Cold water 
drinking. 




§ to 

— <D 
CO 73 
3 O 


o 


si 


Laudanum 
to excess. 


d 
S 

cS 
tS 


to 
O, 

S 


d 

To 

d 
f-i 

3 

« 


to 

<o 

s 


cd 
!S 

d . 

.5 .2 

X 


E 

o 


1331 
1832 
1833 
1834 
1835 
1836 
1837 
1838 
1839 
1840 


4 
3 
8 
5 
3 
2 
2 
4 

2 


4 
3 
3 
2 
4 
2 
7 
6 
1 
1 


3 

3 



3 

6' 

2 

1 

3 


2 

2 
4 


31 
46 

32 
32 
40 
60 
60 
62 


4 


1 
1 

1 

8 
1 

1 


2 
2 
1 

4, 

1 
1 


7 
4 
6 

5 
2 


i 
i 
i 

2 
3 
2 
4 
3 
3 

1 


1 
2 

4 
1 
2 


2 
3 
2 
4 
3 
3 
3 
2 

3 


3 
12 
16 
5 
6 

6 



58 

2 

136 
125 


1 
1 

3 
1 


2 


4 
1 
1 


2 
1 
4 

2 

1 


1 

2 
1 
1 

2 


60 
132 

85 
105 
114 
138 
197 
199 
176 

86 




33 


33 


19 


8 


370 


4 


13 


11 


24 


21 


10 


32 


48 


417 


6 8 


10 




1292 



* These are included under the head of Casualties. 



24 



Emerson on the Vital Statistics of Philadelphia. [July 



Classes considered separately. — The 1st Class, containing the mortality 
from zimotic or epidemic, endemic and contagious diseases, shows for the 
whole decennial period a grand total of 13,652. This constitutes 1 death 
from diseases of this class to 3.63 from all other sources of mortality (49,678). 
Cholera Infantum takes precedence in this appalling list, the number hav- 
ing been 2,769. Next comes scarlatina, the sum total of which is 2,004. 
Next epidemic cholera, the amount under which head is 1,371, which in- 
cludes the deaths from Asiatic cholera in 1832 and 1834. The same 
remark applies to the amount reported under the head of cholera infantum. 
Then comes diarrhoea, 1,227, followed by dysentery 1,020. The whole 
mortality from the four bowel affections— cholera, cholera infantum, diar- 
rhoea and dysentery, is no less than 6,387, being nearly 50 per cent, of the 
deaths from all other diseases included in this class, and 1 in 7-7 of the 
total mortality from all other sources. It is proper to bear in mind that the 
great fatality from intestinal affections in this decennial period includes 
1,225 deaths from Asiatic cholera, to say nothing of those from the same 
disease undoubtedly embraced under the head of cholera infantum and 
other bowel affections. Small-pox has a heav}r sum of mortality charged 
to it, namely, 827 in the 10 years, a great increase on former rates, when 
compared with the whole amount for the previous 21 years, which is 1,225. 
The years of its greatest prevalence as an epidemic were 1833-'34and '35. 
This shows the great importance of vigilance and necessity of enforcing 
protective measures, which should on no account be omitted from the ex- 
emption sometimes manifested during many years. 

Measles occasioned 578 deaths. As the most frequent results of this 
malady are presented in other forms of disease to which it gives rise, the 
amount of mortality occasioned through measles indirectly cannot be ascer- 
tained with any kind of precision, but must, undoubtedly, be very great. 

The deaths from fevers embraced in this class, have been included in a 
separate table F, in which those from scarlet and puerperal fevers have 
been omitted. The whole amount is 4,549, of which there are 425 merely 
denominated fever. Under the specific heads of bilious and remittent, there 
are 687; intermittent, 73; typhus and nervous, 996; making a total under 
these three heads of 1,756. The greatest mortality from febrile diseases 
occurred in the year 1832, when they were 853, and in 1836, when they 
amounted to 769. The columns of this and the table to which it is an 
appendix, show that the annual amounts fluctuate very greatly, the small- 
est having been 275 in 1839, when the number of deaths reported under 
the heads of bilious and remittent were only 47, intermittent 1, and typhus 
and nervous 47, making only 97 deaths from these diseases in this year, 
whilst in the year following the amount was only one more. The pro- 
portion of deaths from fevers to that from all other sources of mortality is 
1 in 10-92. 



1848.] 



Emerson on the Vital Statistics of Philadelphia, 



25 



TABLE F. 



Mortality in Philadelphia from particular Fevers, in each year from 1831 to 1840. 





1831 


1832 


1833 


1834jl835 


1836 


1837 


1838 


1839 1840 


Totals. 


Fevers, not designated 


00 


si 


A P. 

40 


35 


25 








. 32 


24 




" Bilious and re- 
























mittent 


98 


94 


80 


58 


66 


85 


57 


63 


47 


39 


687 


" Intermittent 


15 


15 


7 


3 


3 


13 


5 


3 


1 


8 


73 


" Typhus and 
























Nervous 


92 


210 


84 


61 


42 


220 


107 


70 


47 


63 


996 


Fevers of all other } 


271 


400 


217 


157 


136 


380 


203 


166 


127 


134 


2,181 
























kinds except sear- > 


276 


453 


263 


175 


149 


389 


213 


160 


148 


142 


2,368 


let and puerperal ) 
























Totals 


547 


853 


480 


332 


285 


769 


410 


326 


276 


275 


4,549 



Scarlatina. — The total amount of deaths from this fatal source is, as 
before stated, 2,004, being nearly one-half of the sum total from all other 
fevers, puerperal excepted, and constituting rather more than 4 per cent, of 
the mortality from all other sources. How striking is the contrast with the 
reported mortality from this disease for a quarter of a century previous. In 
the year 1827, not a single death is recorded under this head, in 1828 only 
1 death from scarlet fever is reported in the bill of mortality ; during the 
whole period from 1807 to 1830, including 24 years, the bills of mortality 
only exhibit 150 deaths from scarlet fever. The greatest amount in any 
one year of our decennial period was in 1832, when it rose to 307, the 
smallest in 1833, when it was 61. 

Hooping Cough claims 6?8 victims, the greatest number being in 1839, 
when the amount was 191, and the least in 1840, when only 4 deaths are 
returned under this head. The proportion of deaths from this disease to 
that from all other sources, is 1 in 72, being less than for the 20 years pre- 
vious, when it was about 1 in 63 of the general mortality. 

Croup. — Under this head we find no less than 1023 deaths recorded, the 
highest number in a single year being 127 in 1831, and the lowest 81 in 
1834. In the 20 years from 1807 to 1827, the deaths, reported from croup 
constituted 1 in 51 of the general mortality. During the last decennial 
period, it was I in 48, being a slight increase over former years. 

Class II. — Showing the mortality from diseases of no particular seat, 
as well as sporadic diseases. This presents a grand total of 16,241 deaths, 
constituting about one in three of the general mortality from all sources. 

Phlegmasia. — About half of the grand total just given, is from inflam- 
mations of various kinds, the whole amount of which is 8257. The fatal 
results of the different phlegmasia are exhibited in Table G. 



26 



Emerson on the Vital Statistics of Philadelphia. 



[July 



TABLE G. 

Phlegmasia or Inflammations. 





Of the Lungs 
(Pneumonia) 


Breast 

(Pneumonia) 


I Pleurisy 


Bronchitis 


Croup 


j Catarrh 


| Larynx 


1 Stomach 


j Bowels 
| Colon 


i Peritoneum 


Brain 




i Liver 


| Kidney 


| Bladder 


Throat 


Totals 


1831 


192 


28 


24 


63 


127 


58 




34 


81 4 


23 


89 


5 


42 


2 


4 4 




780 


IQQO 

Looz 


225 


19 


19 


97 


110 


51 




41 


125 




102 


4 


21 


1 


1 2 


24 


842 


1833 


166 


17 


8 


37 


95 


26 


3 


48 


135 8 




72 


2 


IS 


2 


ll 


3 


641 


1834 


169 


15 


11 


121 


81 






41 


111 5 




104 


6 


37 


3 


6 2 


19 


731 


1835 


240 


37 




171 


128 






30 


96 6 


17 


106 


9 


23 


1 


7 3 


12 


886 


1836 


205 


44 




141 


118 




3 


39 


103 3 


25 


96 


8 


17 


4 


3 5 


3 


817 


1837 


226 


42 




146 


104 




5 


34 


111! 1 


24 


108 




26 


1 


3 6 


20 


859 


1838 


230 


41 




118 


101 






43 


1181 2 


25 


150 


i 


21 




5 4 


22 


883 


1839 


228 


27 




148 


83 




4 


35 


175 8 


IS 


111 


s 


30 


2 


2 1 


11 


888 


1840 


211 


28 


14 


112 


79 




4 


41 


110] 7 


24 


157 


,2 


25 




5 1 


11 


846 


Totals 


2092 


298 |T6 


1154 


1026 


135 


19 


386 


1165:44 


156 


1095 


56'260 


2137: • 







Total 



64 



8237 



The deaths from inflammatory affections of the lungs and air passages, 
amount to 4800, being nearly one-half of the deaths, from all kinds of in- 
flammation. Of these, 2390 may be placed under the head of pneumonia ; 
76 of pleurisy ; 1154 of bronchitis ; 1026 of croup ; 19 of the larynx, and 
135 of catarrh. The great mortality from inflammatory affections of the 
lungs and air-passages, shows the importance attached to their prevention 
and treatment. 

Inflammation of the stomach, bowels and peritoneum carried off 1751, 
of which no less than 1165 are under the head of inflammation of the 
bowels. The proportion of deaths from these abdominal affections is about 
one in nine of the deaths from ail the phlegmasia. 

In addition to the deaths from inflammations designated in Table G, 
there were 64 registered during the 10 years, under the following heads, 
viz: inflammation, 28; inflammation of the trachea, 10; spinal marrow, 5; 
vein, 5; arachnitis, 4; parotid gland, 3; spleen, 2; knee-joint, 2; scrotum, 
2; testicle, 1 ; pharynx, 1; aorta, 1. 

TABLE H. 

Mortality in Philadelphia from Dropsical Affections from 1S31 to 1840. 





1831 


1832 


1833 1834 


1835 


1836 


1837 


1838 


1839 


1840 


Total . 




111 


115 


80 


103 


89 


108 


72 


61 


75 


77 


891 


" of the breast 


48 


62 


52 


52 


57 


47 


53 


57 


67 


44 


539 


" of the head. 


208 


187 


170 


198 


214 


162 


192 


195 


193 


145 


1864 


" of the spine 




,2. 










2 








4 


w abdominal 














27 


19 


22 


26 


94 


" ovarian 














1 






1 


2 




367 


36G 


302 


353 


360 


317 


347 


332 


357 


293 


3394 



1848.] 



Emerson on the Vital Statistics of Philadelphia. 



27 



Dropsies.'— The deaths from these are next in amount after those from 
inflammations, being for the whole ten years 3394, constituting about 1 in 
11 of the deaths from all other diseases. No less than 1864, or above one- 
half, are recorded as dropsy of the head, and 539 as dropsy of the chest, 
which two designations embrace about 70 per cent, of the whole mor- 
tality from all kinds of dropsy. The deaths are distributed through the 
different years with remarkable regularity, the highest number being 367 
in 1831, and the lowest 293 in 1840. « 

Debility and Jltrophy. — Under these two vague heads, used so fre- 
quently from ignorance of the specific disease causing death, are included 
no less than 2978 deaths, of which 1912 are set down to debility, and 1066 
to atrophy. 

Abscess. — This head embraces 210 deaths under 14 different heads, of 
which that of abscess without any further designation contains 140; ab- 
scess in the lungs, 26; of the liver and lungs, 13; of the liver alone, 10; 
in the brain, 7; lumbar, 3; hip and leg, 2 ; neck, 2 ; ear, 2; kidneys, 1; 
throat, 1; knee-joint, 1; side, 1 ; abdomen, 1. 

Cancer. — There are 326 deaths from cancer, and 66 from scirrhus, 
making in ail 388 deaths from these sources in the 10 years. Of the 
deaths under the head of cancer, the seats of 192 are undesignated, 55 are 
of the uterus, 26 of the breast, 22 of the stomach, 7 of the mouth, 4 of the 
liver, 3 of the rectum, 3 of the face, 2 of the ovaries, 2 of the neck, 2 of the 
penis, 1 of the intestines, 1 of the leg, 1 of the throat, 1 of the lungs, 1 of 
the tongue. 

Of the deaths recorded under the name of scirrhus, there were 16 the 
seats of which were undesignated, 16 of the stomach, 12 of the liver, 7 of 
the uterus, 4 of the pylorus, 2 of the bowels, 2 of the rectum, 1 of the 
prostate gland, 1 of the breast, and 1 of the ovaries. The deaths reported 
from cancer and scirrhus are spread through the different years with con- 
siderable uniformity, showing a steady increase with that of the general 
population. Beginning with those reported in 1831, the annual sums run 
thus, up to 1840: 20, 32, 39, 42, 41, 36, 39, 51, 38, 46. 

The deaths from hemorrhage have no designation of the different kinds 
until the year 1837, in which, and the three following years, 126 deaths 
are reported, distributed under the following heads : From the lungs, 9 ; 
stomach, 10; bowels, 9; uterus, 8; bladder, 1; gums, 1 ; undesignated, 46. 

Infantile Diseases, whi-ch, according to the mode of classification adopted, 
are embraced in this division, will be the subject of future consideration. 

Class III. Diseases of the Nervous System. — The sum total of deaths 
from this class of affections is formidable, being 8688. 

Convulsions claim, as usual, the largest proportion of victims recorded 
under a separate head, the whole amount during the decennial period 
being 2985. The numbers reported for the various years have considera- 
ble regularity, the highest being 351 in 1835, and the lowest 266 in 1833. 



28 



Emerson on the Vital Statistics of Philadelphia. 



[July 



The deaths from convulsions constitute more than one-third of those from 
all diseases of the nervous system. Being generally the result of some 
particular affection of the brain, the term convulsion commonly designates 
but a symptom, and not the specific disease or true cause of death. 

Hydrocephalus is charged with 1864 deaths, cephalitis 1095, delirium 
tremens 826, apoplexy 704, palsy 471, epilepsy 108, insanity 104, tetanus 
51, and chorea 10. 

The column numbered 41, embraces the deaths reported in the bills of 
mortality from diseases of the brain not specified in the table. The whole 
amount is 470, distributed as follows : ' Disease of the brain, 231; con- 
cussion of the brain, 12; compression of the brain, 9; congestion of the 
brain, 123 ; effusion on the brain, 38; irritation of the brain, 7 ; abscess in 
the brain, 7; softening of the brain, 34; suppuration of the brain, 1 ; in- 
jury of the brain, 7; tumour on the brain, 1. 

The columns representing the deaths annually from delirium tremens 
and insanity, both exhibit a very considerable decline in the last years of 
the series. This is mainly owing to the fact that the public institutions, to 
which most of such cases are committed, have been removed beyond the 
limits of the Board of Health. Part of the diminution is, however, doubtless 
owing to the progress which temperance societies have made in checking 
and reforming bad habits, aided by the happy influences exerted upon 
communities by the spread of intelligence. 

Class IV, containing the Deaths from Diseases seated in the Organs 
of Respiration. — Many of these have already been presented under dif- 
ferent heads, in the tables exhibiting the deaths from the phlegmasia, and 
dropsies appertaining to Class II. Taking the whole amount of mortality 
reported in the bills under the heads of inflammation of the lungs and 
pneumonia, 2092, — inflammation of the breast and chest, 298, — pleurisy, 
76, — bronchitis, 1154, — croup, 1028, — catarrh, 135, — inflammation of the 
larynx, 19, — asthma, 93, — consumption, 7070, — we have a grand total of 
11,963 deaths during the decennial period, from diseases located in the 
lungs and air-passages. 

The mortality from these sources, when compared with that from all 
others, is about 1 to 4. The amount from consumption alone comprises by 
far the greatest portion, being 7070 for the 10 years, or 1 in 7 of the deaths 
from all other diseases, and about 1 death per annum to 282 of the general 
population. The ratio of mortality from this direful scourge, though much 
lower than iu some others of our Jarge cities, is increased by the greater 
prevalence of phthisis among the large coloured population. Could the 
deaths from consumption of the whites be separately estimated, the ratio 
of mortality would be much less, and especially so could there be a deduc- 
tion of the interments of the many strangers who resort to Philadelphia for 
amelioration of this disease in its advanced stages. 

The annual sums of mortality from consumption, present a very regular 



1848.] 



Emerson on the Vital Statistics of Philadelphia. 



29 



increase, the highest number being 777 in 1840, and the lowest 636 in 
1834. The lowest ratio of mortality to the general population was in 1839, 
when it was 1 to 325 inhabitants, and the highest in 1831, when it was 1 
in 259. 

Class V. Deaths from Diseases of the Organs of Circulation. — The 
manner in which the bills of mortality have been made out, does not admit 
of the filling up of but one of the three columns devoted to this class. The 
deaths from inflammation of the heart will be found in the table devoted to 
the phlegmasia, whilst those from diseases of some other organs of the cir- 
culation, are scattered through other tabular statements. 

The deaths recorded from diseases of the heart amount to 339, distributed 
as follows : diseases of the heart, 240 — hypertrophy of the heart, 90 — 
ossified valves, 4- — dilatation, 5. 

Class VI. Diseases seated in the Digestive Organs. — By far the largest 
amount of deaths from diseases in these organs, is embraced in Class I., 
under the heads of cholera, diarrhoea, dysentery, &c. The total mor- 
tality charged to Class VI., is 2516, and more than one half of this amount 
is from phlegmasia already mentioned, such as enteritis, gastritis, etc. 

Class VII. Diseases situated in the Urinary Organs, only furnish 74 
deaths in the whole decennial period. Of these, 11 are from diabetes, 
37 cystitis, 5 gravel, and 21 nephritis. To the deaths from gravel we 
may add 8 from a column of the unclassified diseases headed calculus, 
making the whole number of deaths from gravel and stone 13. 

Class VIII. Diseases of the Organs of Generation exhibit a mortality 
of 197, all of which are from affections peculiar to females, and attendant 
upon parturition. Puerperal fever is charged with 144 deaths, and 63 
are indefinitely ascribed to " childbirth." 

Class IX. Diseases of the Organs of Locomotion. — Of these, number- 
ing in ail 132, rheumatism is charged with 73, hip joint disease with 27, 
and spinal disease with 32. 

Class X. — Diseases of the Integumentary System embrace 128 deaths 
under three heads, of which 107 are from ulcers, 18 purpura, and 3 fistula. 

Class XL— The column headed Deaths from Old &ge, contains 828. 
Of these, there are placed between the 50th and 60th year, 21; between 60th 
and 70th, 66; between 70th and 80th, 246 ; between 80th and 90th, 369 ; 
between 90th and 100th, 130; between 100th and 110th, 29, and over 110, 
1. In 1832, the bills commence distinguishing the males and females 
under this head, and it appears that, out of 788 deaths reported, 530 
were females, and only 258 males. 

Under the indefinite head of " Congestion," we have 370 deaths re- 
corded, with the following designations : — Of the liver, 4 ; lungs, 123 ; 
brain, 238; not specified, 5. 

The deaths ascribable to " External Causes" are distributed under a 
great many heads. There are no less than 547 under that appropriated to 
No. XXXI.— July, 1848. 3 



30 



Emerson on the Vital Statistics of Philadelphia. 



[July 



the" Drowned," and 261 in that of 4 ' Burns and Scalds." "Excessive Heat" 
is charged with 50 deaths, 16 of which were in 1834, and 26 in 1838 ; 
29 are registered " Frozen," of which 8 were in 1836,6 in 1839, 4 in 
1835, and 4 in 1840. Intemperance numbers 243 deaths, suicide 115, 
wounds 33, poisoned 58, killed by design 17, by lightning 3, executed 2, 
hydrophobia 5, starved 98. 

The still-born, in the ten years, amount to 3222, being rather under 6£ 
per cent, of the whole mortality, and about 1 to 24 live births. 

For nine years of the decennial period, from 1832 to 1840 inclusive, 
the sexes of the still-born are designated. Of 2906 reported cases, 1665 
were males, and 1241 females. The sexes were not given separately in 
1831. This head undoubtedly embraces the dead-born at all periods of 
gestation. It would be interesting to have the sexes of the still-born, 
strictly so called, distinguished from those of the dead-born at the natural 
period of gestation, as this would show the amount of the greater risks run 
in parturition by the males. 

TABLE J. 



Deaths in Philadelphia for each Month often years, from 1831 to 1840, with a designation of 
those which occurred over and tinder the 20th year. 





January. 


February. 


March. 


April. 


May. 


June. 


Year. 


13 
< 


•a o 

£ of 
P 


"3 
O 
Eh 


to 

"a 
< 


:§§ 

p 


to 
cS 
O 

Eh 


to 

< 


*o © 

p 


to 

O 
Eh 


"3 

< 


0) . 

© 

a cm 

P 


to 

~B 
o 
Eh 


to 

a 

ra 

< 


OJ . 
T3 O 

C CM 
P 


ej 
o 
Eh 


"a 
< 


<u . 

O 
S CM 
P 


Is 
o 
E- 


1831 
1832 
1833 
1834 
1835 
1836 
1837 
1838 
1839 
1840 


159 
253 
203 
200 
186 
182 
216 
247 
189 
241 


147 

361 
192 
212 
288 
275 
274 
222 
279 
297 


306 
614 
395 
412 
474 
457 
491' 
469 
46£ 
538 


166 
151 
152 
160 
170 
165 
175 
169 
164 
174 


170 
324 
168 
194 
260 
222 
221 
239 
237 
206 


336 
475 
320 
354 
430 
387 
396 
408 
401 
380 


156 
218 
ISO 
181 
216 
177 
192 
174 
203 
156 


173 
298 
186 
234 
246 
196 
235 
242 
282 
241 


329 
516 
366 
415 
462 
373 
427 
416 
485 
397 


197 
215 
175 
160 
197 
254 
257 
174 
147 
222 


162 
257 
148 
152 
373 
225 
286 
322 
209 
273 


359 
472 
323 
312 
570 
479 
543 
496 
356 
495 


148 
274 
178 
154 
158 
231 
156 
144 
138 
142 


164 
299 
179 
167 
305 
149 
186 
228 
184 
193 


312 
573 
357 
321 
463 
380 
342 
372 
322 
335 


114 
179 
141 
121 
155 
204 
145 
134 
131 
163 


198 
211 
209 
210 
312 
182 
181 
210 
296 
204 


312 
390 
350 
331 
467 
386 
326 
344 
427 
367 


Totals 


2076 


2547 4623 


1646 


2241 


3887 


1853 


2333 


4186 


1993 


2407 


4405 


1723 


2054 '3777 

1 


14=7 


2213 


3700 





July. | 


August. 


September. 


October. 


November. 


December 


Year. 


to 

a 
< 


S-i 

<D . 
X> © 
= CM 

p 


"a 
o 

Eh 


a rao 
•a cCM 
< P 


o 
Eh 


to 
< 


P 


~§ 
o 
Eh 


to 

<J 


^ ~ 
•a o 
a cm 
p 


to 

5 
o 

Eh 


to 

^5 


>- | to 

■sal 1 

P j EH 


m 
3 

< 


fH 
P 


o 
Eh 


1831 
1832 
1833 
1834 
1835 
1836 
1837 
1838 
1839 
1840 

- 


178 
200 
224 
261 
197 
260 
222 
273 
196 
253 


407 
365 
362 
506 
478 
310 
417 

379 

385 


585 
565 
580 
767 
675 
j 570 
639 
E-70 
575 
638 


156i 286 
1099 590 
162; 240 
163 311 
162 1 365 
216 3(9 
173 376 
175 425 
154 363 
158 281 


442 
1689 
402 
474 
527 
505 
549 
600 
517 
439 


206 
215 
167 
219 
189 
229 
194 
20^ 
147 
184 


275 
234 
180 
214 
335 
301 
295 
321 
237 
203 


481 
449 
347 
433 
524 
530 
489 
529 
384 
387 


175 
194 
199 
347 
143 
189 
153 
162 
206 
192 


203 
192 
161 
242 
203 
194 
187 
175 
215 
.214 


378 
386 
360 
589 
346 
382 
340 
337 
421 
406 


184 
130 
166 
146 
130 
209 
142 
143 
144 
146 


207 391 
127 257 
149 315 
165 311 
207 337 
187; 397 
168, 310 
153 296 
178 322 
123 274 


380 
136 
152 
177 
149 
235 
167 
150 
133 
150 


328 
177 
167 
177 
242 
265 
181 
161 
189 
153 


70S 
313 
319 
354 
391 
500 
348 
311 
322 
303 


Totals. 


2264 


1206 647(i 

1 


26 is 3546 

1 


6164 


19.3 


2595 


4553 


I960 


1986 3946 

1 


1540 


1669 3209 

! 


1829 


2040 


3869 



1848.] Emerson on the Vital Statistics of Philadelphia. 31 



Monthly Mortality. — In Table J, the deaths during ten years are dis- 
tributed among the different months in which they occurred, showing the 
influence of the seasons upon the mortality of both adults and children. It 
may be interesting to compare the results with those presented in the 
second series of statistical calculations, published in the American Journal 
of the Medical Sciences for November, 1831. Among the most conspicu- 
ous developments is that of the diminution of the sums of the general 
mortality for those months in which a moderate temperature prevails, such 
as May and October, compared with the augmentation of the sums for the 
cold, but more especially for the warmest months, chiefly from the un- 
favourable effects of extreme heat upon infants. 

The months, when arranged according to the decreasing mortality of the 
general population of all ages, take the following order, the short months 
having been equalized: 1st, July, 6470 ; 2d, August, 6164; 3d, Septem- 
ber, 4704; 4th, January, 4623 ; 5th, April, 4551; 6th, February, 4301; 
7th, March, 4186; 8th, October, 3946; 9th, December, 3869; 10th, 
June, 3823 ; 11th, May, 3777; 12th, November, 3306. 

During the four last years of the decennial period, the bills of mortality 
exhibit the monthly deaths of the coloured inhabitants separately. The 
following statement will show the influence of the seasons upon this divi- 
sion of the population, numbering about 18,000. 





Jan. 


Feb. 




April 


May 


June 


July 


fc'c 

3 

<! 


Sep. 


O 


Nov. 


Dec. 


Total. 


1837 


46 


41 


45 


69 


41 


43 


73 


41 


47 


40 


30 


52 


568 


1838 


60 


46 


53 


69 


51 


36 


93 


65 


62 


34 


33 


47 


649 


1839 


49 


54 


63 


48 


37 


47 


65 


52 


40 


55 


34 


40 


584 


1840 


55 


41 


38 


70 


30 


43 


80 


31 


27 


37 


26 


29 


507 


Monthly totals, 


210 


182 


199 


256 


159 


169 


311 


189 


176 


166 


123 


168 


2308 



The months, when arranged so as to show the decreasing mortality of 
the coloured population alone, take the following order, which will be 
found considerably different from that exhibited by the general mortality : 
1st, July, 311; 2d, April, 256; 3d, January,210; 4th, February, 200; 5th, 
March, 199 ; 6th, August, 189 ; 7th, Sept., 176 ; 8th, June, 169 ; 9th, 
Dec, 168; 10th, October, 166; 11th, May, 159; 12th, November, 123. 



32 



Emerson on the Vital Statistics of Philadelphia. 



[July 



TABLE K. 



Monthly Mortality in Philadelphia in four consecutive years, from 1837 to 1840, at various ages 

up to the 20th year. 



Month. 


Under 1 y'r. 
(still born 
excluded.) 


Between 
1st and 2d 
year. 


Between 
2d and 5th 
year. 


Between 
5th and 
10th year. 


Between 
lutn ana 
20th year. 


Totals. 


Months 
equalized. 


January ' 


422 


184 


202 


90 


55 


953 


953 


February- 


342 


158 


165 


66 


58 


789 


868 


March 


400 


152 


194 


76 


64 


886 


886 


April 


429 


177 


210 


97 


63 


976 


992 


May 


268 


118 


166 


65 


60 


677 


677 


June 


413 


123 


133 


47 


61 


777 


806 


July 


1030 


360 


184 


92 


88 


1754 


1754 


August 


657 


397 


160 


87 - 


60 


1361 


1361 


September 


451 


268 


178 


67 


56 


1020 


1054 


October 


299 


123 


132 


61 


58 


673 


673 


November 


222 


95 


114 


38 


44 


513 


527 


December 


238 


98 


132 


53 


49 


570 


570 




5,171 


2,253 


1,970 


839 


716 


10,979 





The effects of the fatal influences exerted in particular months upon 
the different ages under the 20th year, are shown in Table K, where the 
monthly deaths at the various periods of life designated in the bills of mor- 
tality, are given for four consecutive years. In the column next to the last, 
are the actual totals for the several months, which, having different lengths, 
do not, of course, present the proportional mortality for an equal space of 
time. We have therefore equalized the months in the last column, so as 
to give to the short the proportions of the long months. 

It will be seen that the mortality in the first year of life was 5,171, which 
is about 47 per cent, of the whole mortality under the 20th year, (10,979,) 
and about 27 per cent, of the mortality at all ages. The deaths under the 
5th year amount to 9,394, constituting about 86 per cent, of the whole 
mortality under the 20th year, and leaving but 16 per cent, for the suc- 
ceeding 15 years of life. Compared with the total mortality at all ages, 
that under the 5th year comprises" 49 per cent., and that under the 20th 
year, 56 per cent. 

When we compare the several months for the purpose of ascertaining their 
proportional infantile mortality, we find them in the equalized column tak- 
ing the following order, commencing with the highest totals: July, 1754; 
August, 1361; September, 1054; April, 992; January, 953; March, 886; 
February, 868; June, 806; May, 677; October, 673; December, 570; 
November, 527. After the 2d year of life, the columns exhibiting the 
deaths during the subsequent 18 years, present comparatively slight fluc- 
tuations with the changing seasons. Casting the eye down the 1st and 2d 
columns, the swelling of the numbers representing the mortality in June, 



1848.] Buel, Statistics of imputations in N. Fork Hospital. 33 



July, August and September, is very conspicuous, whilst in the columns 
containing the deaths after the 2d year of life, little, if any, increase is per- 
ceptible during the warm months. On the contrary, after the 2d year, the 
warm months seem more favourable to life than the cold months. This 
fact — the destructive influence exerted by the hot season upon infantile 
life, and its limitation almost to the first year of existence, — is a subject 
which we have formerly treated of in the paper referred to, published in 
the American Journal of the Medical Sciences for November, 1831. 



Art. II. — Statistics of imputations in the New York Hospital, from 
January 1st, 1839, to January 1st, 1848. By Henry W. Buel, M.D., 
Resident Surgeon. 

The importance of accurate knowledge with regard to such an operation 
as that of amputation, will hardly be questioned. By the ancients, unac- 
quainted as they were with the circulation of the blood, or the proper 
means of arresting its flow, this operation was dreaded and avoided. To 
such an extent were they impressed with its danger, that we even find it 
recommended that "a limb should be allowed to drop off rather than to cut 
it off." As the operation advanced more nearly to perfection, we find Mr. 
Benjamin Bell saying, " In the present improved state of the operation, I 
do not imagine that one death will happen in twenty cases, even including 
the general run of hospital practice." 

Opinions similar to this last have been held until quite recently, and are 
probably even yet entertained by some, if not many, surgeons. 

Within a few years, however, the subject has attracted more careful ex- 
amination. Mr. Benjamin Phillips of London, and M. Malgaigne of Paris, 
have published statistical accounts of amputations performed in the respect- 
ive countries where they reside. The former gentleman has also extended 
his observations into other countries. 

In our own country, Dr. Norris of Philadelphia, and Dr. Hayward of 
Boston, have published accounts of hospital amputations. 

The following tables include all the amputations, so far as they can at 
present be collected, that have been performed at the New York 'Hospital 
during the nine years included between Jan. 1st, 1839, and Jan. 1st, 1848. 
Unfortunately there is a portion of time embracing the cases occurring in 
one of the two surgical divisions of the hospital, during parts of the years 
1842 and 1843, of which, owing to the loss of one of the twelve volumes 
of the hospital case books, a full account cannot at present be obtained. 



34 Buel, Statistics of Amputations in JV. York Hospital. [July 

AMPUTATION AT 



No. 


Name. 


Age. 


Disease or injury. 


1 


William Cahill 


22 


Thigh severed by railroad car 



AMPUTATIONS OF 



No. 


Name. 


Age. 


Disease or injury. 


1 


Michael Powell 


28 


Fracture, 2d time 


2 


James Duffy 


40 


Compound fracture of both thighs, R.R. 


3 


Hugh Murphy 


27 


Comminuted fracture, R.R. 


4 


John Langen 


19 


Disease of knee-joint, 2 years 


5 


Sarah Ann Smith 


40 


Encephaloid tumour 


6 


Peter Titus 


29 


Disease of knee-joint, 8 months 


7 


Mary Ann Murray 


7 


Comminuted fracture 


8 


Joseph Peabody 


20 


Fungus hematodes of knee 


9 


Joseph Barr , 


15 


Fracture followed by mortification 


10 


James Foley 


45 


Fracture at neck of femur, gangrene 


11 


John M'Kane 


46 


Comminuted fracture, at ferry 


12 


Morris O'Rourke 


25 


Compound fracture into knee-joint, R.R. 


13 


Thomas Lee 


15 


Compound fracture of leg, at sea 


14 


James Robertson 


31 


Disease of knee-joint, 3 years 


15 


John Colbert 


54 


Compound fracture, R.R. 


16 


Thomas Fallow 


16 


Disease of knee-joint, 7 months 


17 


John W. Leonard 


52 


Compound fracture, sec. hemorrhage 


18 


Ebenezer Armstrong 


45 


Compound fracture 


19 


William Hollaham 


22 


Disease of knee-joint, 7 years 


20 


Thomas Halfpenny 


30 


Disease of knee-joint, 3 years 


21 


John Hackett 


38 


Abscess of thigh 


22 


Henry Wilson 


27 


Gunshot wound of thigh 


23 


John Buiner 


36 


Disease of knee-joint, 3 years 


24 


Thomas M'lvoy 


27 


Comminuted fracture 


25 


John Halligan 


26 


Disease of knee-joint,, 3 months 


26 


Samuel Sheller 


22 


Disease of knee-joint, 2 months 


27 


Sarah Kells 


24 


Disease of knee-joint, 2 years 


28 


Samuel H. Drummond 


34 


Disease of knee-joint, 2 months 


29 


Thomas Brannard 


14 


Diffused abscess of thigh and leg 


30 


Thomas M'Nestry 


25 


Comminuted fracture 


31 


John C. Voorhis 


39 


Compound fracture, followed by gangrene 


32 


William H. Price 


27 


Disease of knee-joint, 5 months 


33 


Hugh Chittuck 


24 


Disease of knee-joint, 12 months 


34 


William Fisher 


66 


Compound fracture of thigh 



AMPUTATION AT 



No. 


Name. 


Age. 


Disease or injury. 


1 


Ellen Callighan 


35 


Burn of foot, leg and thigh 



1848.] Buel, Statistics of imputations in N. York Hospital. 35 
THE HIP-JOINT. 



Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


January 8, 1847 


January 10, 1847 


Died 


January 10, 1847. 



THE THIGH. 



Date of admission. 



Date of operation. 



Result. 



Date of discharge or death. 



March 31, 1838 
July 4, 1839 
July 16, 1839 
August 19, 1839 
September 3, 1839 
May 30, 1840 
July 26, 1841 
October 6, 1841 
September 23, 1841 
October 11, 1841 
December 20, 1S41 
February 20, 1842 
February 9, 1842 
September 8, 1842 
November 25, 1843 
June 13, 1843 
November 28, 1843 
June 19, 1844 
August 23, 1844 
November 13, 1844 
January 18, 1845 
October 21, 1844 
December 7, 1844 
July 11, 1845 
July , 1845 
August 16, 1845 
January 6, 1846 
August 16, 1845 
April 7, 1846 
November 28, 1845 
July 4, 1846 
January 19, 1847 
March 20, 1847 
August 30, 1847 



March 14, 1839 
July 4, 1839 
July 16, 1839 
August 22, 1839 
September 12, 1839 
June 26, 1S40 
July 26, 1841 
October 7, 1841 
October 18, 1841 
October 29, 1841 
December 20, 1841 
February 20, 1842 
March 2, 1842 
January 20, 1843 
November 25, 1843 
January 6, 1844 
January 27, 1844 
June 19, 1844 
September 10, 1844 
November 28, 1844 
February 11, 1845 
February 20, 1845 
March 11, 1845 
July 15, 1845 
October 11, 1845 
January 10, 1846 
January 12, 1846 
February 7, 1846 
April 19, 1846 
April 20, 1846 
July 9, 1846 
February 13, 1847 
June 7, 1847 
September 30, 1847 



Died 

Died 

Cured 

Cured 

Cured 

Died 

Cured 

Died 

Cured 

Cured 

Died 

Died 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Died 

Cured 

Cured 



March 24, 1839. 
July 7, 1839. 
October 7, 1839. 
November 26, 1639. 
November 23, 1839. 
July 26, 1840. 
November 27, 1841. 
December 3, 1841. 
January 4, 1842. 
January 31, 1842. 
December 24, 1841. 
February 25, 1842. 
June 25, 1842. 
February 28, 1843. 
November 25, 1843. 
March 11, 1844. 
June 18, 1844. 
October 16, 1844. 
November 8, 1844. 
January 18, 1845. 
May 20, 1845. 
March 6, 1845. 
May 1, 1845. 
August 25, 1845. 
December 9, 1845, 
February 20, 1846. 
May 12, 1846. 
March 26, 1846. 
May 6, 1846. 
October 12, 1846. 
November 20, 1846. 
February 18, 1847. 
August 3, 1847. 
April 10, 1848. 



THE KNEE-JOINT. 




/ 




Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


January 27, 1846 


February 9, 1846 


Died 


March 7, 1846. 



36 Buel, Statistics of Amputations in N. York Hospital. [July 



AMPUTATIONS OF 



No. 


Name. 


Age. 


Disease or injury. 


1 


Lydia Cunningham 


10 


Compound fracture of leg, R.R. 


2 


Peter Connell 


28 


Irritable stump, after amputation at sea 


3 


Christopher Mumford 


54 


Compound fracture from bursting of a cannon 


4 


Patrick Farley 


23 


Comminuted fracture, mortification 


5 


Charles J. Titcomb 


23 


Caries of tibia of long duration 


6 


Thomas Lawless 


45 


Compound fracture of leg 


7 


Michael Parker 


30 


Scrofulous disease of ankle, 15 months 


8 


Mary Gray 


45 


Compound fracture of leg 


9 


Edwin Marshall 


35 


Compound fracture of leg 


10 


Henry C. Frink 


35 


Malignant tumour of leg 


11 


Richard Shepherd 


51 


Compound and comminuted fracture of foot 


12 


Owen Quin 


50 


Compound and comminuted fracture of leg 


13 


Patrick Shay 


37 


Compound and comminuted fracture of leg, R.R. 


14 


Matthew Henessey 


22 


Compound fract. of leg and fract. of vertebrae 


15 


Martin Durkin 


30 


Comminuted fracture of tarsus, fibula, &c, R.R. 


16 


John Galligan 


11 


Compound dislocation of ankle, &c. 


17 


Thomas Stewart 


26 


C Compound fracture of tib., fr. humeri and comp. 
( fr. rad. and uln. 


18 


William Henry Short 


30 


Disease of ankle-joint, after erysipelas 


19 


Patrick Tenman 


28 


Compound fracture and dislocation of ankle 


20 


John Egan 


25 


Comp. fr. of tib. and fib., simp. fr. of femur, R.R. 


21 


Patrick Everard 


45 


Compound fracture of tarsus, fib., &c, R.R. 


22 


Albert Stone 


12 


Laceration followed by sloughing, R.R. 


23 


Charles Hemmaling 


25 


Chronic disease of ankle-joint, 3 months 


24 


Morris Marra 


50 


Compound fracture of tib. and fibula 



AMPUTATIONS AT 



No. 


Name. 


Age. 


Disease or injury. 


1 


David Jarvis 


19 


Laceration of arm by gunshot 


2 


John Maloney 


37 


Burn from sleeve taking fire 


3 


George Hamilton 


23 


Burn, 5 months 


4 


Hannah Murphy 


30 


Burn 


5 


Robert Cannon 


21 


Arm torn off in falling from a height 


6 


Ellen Shannon 


4 


Burn, arm sphacelous 


7 


Heinrich Bordmann 


32 


Arm torn to shreds in machinery 


8 


Margery M'Vernon 


70 


Burn 


9 


James M'Vickar 


34 


Comminuted fracture of os brach., gangrene 



AMPUTATIONS OF 



No. 



Name. 



1 Richard Fisher 

2 Michael Aymer 

3 Gottfried Sporling 

4 John Lamphine 

5 Alexander Dalrymple 

6 James Hagan 

7 John Bel ford 

8 Charles Peterson 

9 George Fisher 

10 John Gannen 

11 Hugh Sheridan 



Disease or injury. 



Scrofulous disease of elbow-joint, 3 months " 

Compound fracture of forearm 

Wound of arm, mal-treated 

Inflammation of hand and forearm, gangrene 

Compound and comminuted fracture 

Scrofulous disease of elbow-joint 

Arm torn by machinery 

Arm torn off by machinery 

Compound fracture of rad. uln. and os brach. 

Compound fracture of os brach. 

Forearm torn off by machinery 



1848.] 



Buel, Statistics of Amputations in N. York Hospital. 



37 



THE LEG. 



Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


August 3, 1839 
May 4, 1840 
July 4, 1840 
May 13, 1841 
August 5, 1841 
September 3, 1841 
September 15, 1841 
December 27, 1841 
May zo, J 844 
July 30, 1844 
June 25, 1845 
May 2, 1846 
May 21, 1846 
September 11, 1846 
January 5, 1847 
March 28, 1847 


August 3, 1839 
May 4, 1840 
July 4, 1840 
May 13, 1841 
August 10, 1841 
September 3, 1841 
•November 4, 1841 
January 9, 1842 

-T\/r„ „ oO 1 QA A 

May zo, lo44 
July 31, 1844 
June 25, 1845 
June 4, 1846 
May 21, 1846 
September 11, 1846 
January 5, 1847 
March 28, 1847 


Cured 

Cured 

Died 

Died 

Died 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 


November 4, 1839. 
July 30, 1840. 
July 9, 1840. 
May 14, 1841. 
September , 1841. 
December 13, 1841. 
March 1, 1842. 
May 10, 1842. 
June o, 1844. 
September 21, 1844. 
August 1, 1845. 
August 3, 1846. 
August 7, 1846. 
October 5, 1846. 
March 9, 1847. 
May 22, 1847. 


June lb, lo47 


J une lo, io4 / 


uiea 


J une zo, lc54 / . 


May ll, 1847 
July 14, 1847 
August 4, 1847 
October 7, 1847 
September 30, 1847 
May 23, 1847 
September 4, 1847 


June 27, 1847 
July 21, 1847 
August 4, 1847 
October 8, 1847 
October 25, 1847 
October 25, 1847 
November 19, 1847 


Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 


October 11, 1847. 
September 25, 1847. 
October 18, 1847. 
October 8, 1847. 
February 3, 1848. 
March 6, 1848. 
January 29, 1848. • 


THE SHOULDER-JOINT. 


Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


October 5, 1839 
November 21, 1S40 
July 21, 1841 
December 25, 1841 
August 14, 1844 
January 30, 1845 
April 7, 1846 
December 11, 1846 
April 12, 1847 


October 5, 1839 
November 21, 1840 
October 30, 1841 
January 17, 1842 
August 14, 1844 
January 31, 1845 
April 7, 1846 
December 15, 1846 
April 17, 1847 


Cured 

Cured 

Cured 

Cured 

Cured 

Died 

Died* 

Died 

Died* 


January 4, 1840. 
February 2, 1841. 
December 11, 1841. 
June 10, 1842. 
December 30. 1844. 
February 28, 1845. 
April 16, 1846. 
December 17, 1846. 
April 24, 1847. 


THE ARM. 


Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


May 20, 1839 
October 8, 1841 
November 16, 1843 
January 2, 1844 
May 19, 1845 . 
July 21, 1845 
September 25, 1845 
June 24, 1846 
September 29, 1847 
October 12, 1847 
December 8, 1847 


July 30, 1839 
October 8, 1841 
November 16, 1843 
May 10, 1844 
May 19, 1845 
July 30, 1845 
September 25, 1845 
June 24, 1846 
September 29, 1847 
October 12, 1847 
December 9, 1847 


Cured 
Cured 
Cured 
Cured 
Cured 
Cured 
Cured 
Cured 
Cured 
Cured 
Cured 


October 22, 1839. 
November 29, 1841. 
April 8, 1S44. 
June 28, 1844. 
June 22, 1845. 
September 4, 1845. 
October 29, 1845. 
July 21, 1846. 
October 23, 1847. 
December 30, 1847. 
January 17, 1848. 



* Died of tetanus. 



38 Buel, Statistics of Amputations in N. York Hospital. [July 



AMPUTATIONS OF 



No. 


Name. 


Age. 


Disease or injury. 


1 


Joseph Lyle 


Z\i 


Injury ot wrist, 2 years 


2 


Patrick Madden 


22 


Injury of hand from explosion 


3 


Henry Dowling 


28 


Laceration of hand 


4 


Edward Mullen 


36 


Scrofulous disease of wrist, 4 years 


5 


William Harrison 


21 


Gunshot wound of hand 


6 


Thomas Harney 


50 


Compound fracture 


7 


E. Latham 


63 


Carcinoma of hand 


8 


John Mehill 


28 


Compound and commin. fract. from machinery 
Scrofulous disease of hand, 4 months 


9 


John J. Smith 


49 


10 


Charles Bradley 


46 


Laceration of hand 


11 


James Karsley 


52 


Phlegmonous erysipelas and sloughing 



It will be seen that the whole number of amputations here presented 
amounts to ninety-one; of which, twenty-six were fatal; making the mor- 
tality 28-57 per cent. 

Of amputations at the hip-joint there was one, and that fatal. 

Of amputations of the thigh, the whole number was thirty-four, of which 
ten were fatal; making the mortality 26*47 per cent. 

At the knee-joint there was one amputation, and that fatal. 

Of amputations of the leg, the whole number was twenty-four, of which, 
seven were fatal; making the mortality 29*16 per cent. 

Of amputations at the shoulder-joint, the whole number was nine; of 
which four were fatal; making the mortality 44*44 per cent. 

Of amputations of the arm, the whole number was eleven, of which none 
were fatal. 

Of amputations of the forearm, the whole number was thirteen; of 
which three were fatal ; making the mortality 28*07 per cent. 

So that we have sixty amputations of the lower extremity; of which 
nineteen were fatal; making the mortality 31*66 per cent. 

While of thirty-three amputations of the upper extremity, seven were 
fatal; making the mortality 21*21 per cent. 

With regard to the methods employed in these various operations, the 
reports of the cases do not, in every instance, specify the method; but in 
forty-nine cases, (the whole number in which it is specified,) twenty-four 
were performed by double-flap operation, and twenty-five by circular ope- 
ration. Of the first number, four were fatal; making the mortality 17*66 
per cent. Of the last, three ; making the mortality 12 per cent. 

Of the double-flap operations, there were fifteen of the thigh, of which 
two were fatal; three of the leg, of which one was fatal; four of the arm 
and one of the forearm, of which none were fatal. 

Of the twenty-five circular operations, six were of the thigh, of which 
none were fatal; fifteen were of the leg, of which three were fatal; three 
were of the arm, and one of the forearm, of which none were fatal. 



1848.] Buel, Statistics of Amputations in N. York Hospital. 39 



THE FOREARM. 



Date of admission. 


Date of operation. 


Result. 


Date of discharge or death. 


January 29, 1839 , 
July 4," 1839 
July 15, 1839 
October 20, 1841 
April 10. 1844 
June 3, 1844 
January 10, 1845 
May 26, 1845 
April 15, 1845 
September 26, 1845 
January 18, 1847 


February 13, 1839 
July 4, 1839 
July 15, 1839 
October 23, 1841 
April 10, 1844 
June 3, 1844 
January 17, 1845 
May 26, 1845 
June 17, 1845 
November 15, 1845 
February 27, 1847 


Died 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 


June 22, 1839. 
July 29, 1839. 
August 31, 1839. 
December 20, 5841. 
May 10, 1844. 
September 5, 1844. 
February 26, 1845. 
June 17, 1845. 
July 14, 1845. 
January 1, 1846. 
April 26, 1847. 



Secondary hemorrhage occurred in only one of these forty-nine cases, 
and in that, it occurred twice. 

There were, in the whole number, two other cases, making, in all, three 
cases of secondary hemorrhage. The greater mortality of the flap opera- 
tion may, perhaps, be attributed to the greater proportion of thigh amputa- 
tions performed in that manner. 

As to the question, whether primary or secondary amputation is prefer- 
able, it is evident, that an equal number of similar cases should be selected 
from each class, in order to institute anything like a just comparison. It 
is customary at the New York Hospital, when amputation is demanded 
after severe injuries, to operate before the accession of inflammatory action. 
So that, strictly speaking, the occasions for secondary amputations will be 
comparatively rare. 

Of the whole number of amputations, sixty-two were the result of inju- 
ries, and were fatal in nineteen cases; making the mortality 30-64 per 
cent. 

Of these, thirty-six were primary amputations ; of which there were of 
the hip-joint one, and that fatal; of the thigh, seven, of which four were 
fatal; of the leg, twelve, of which five were fatal ; of the arm, seven, and 
of the forearm, five, of which none were fatal. Making the mortality 
27-77. 

The remaining twenty-six amputations may all be said to have resulted 
from injuries of a more or less severe character; but, as will be seen, they 
were performed at very different periods after the original injury. 

Of this number, eleven were amputations of the thigh, of which three 
were fatal. At the knee-joint, one, which was fatal; of the leg, seven, of 
which one was fatal. At the shoulder-joint, five, of which three were 
fatal; of the arm, one, and of the forearm, one, of which neither was 
fatal; making the mortality 30-76 per cent. 

The number of operations for various chronic affections was twenty-nine, 
of which six were fatal. Of the thigh there were eighteen, of which 
four were fatal. Of the leg, five, of which none were fatal ; of the arm s 



40 » Buel, Statistics of imputations in N, York Hospital. [July- 
three, of which none were fatal ; of the forearm, four, of which two were 
fatal. Making the mortality 20*67 per cent. 

The ages of the patients operated upon were as follows: — 



Under 


10 years of 


age, 4, 


of whom 


1 died. 


Between 10 and 20, 


11, 




1 " 




20 and 30, 


32, 


a 


12 " 


u 


30 and 40, 


21, 


(c 


5 " 


a 


40 and 50, 


11, 




4 « 


it 


50 and 60, 


9, 


a 


2 " 


u 


60 and 70, 


2, 




o' " 


u 


70 and 80, 


1, 


Cf 


1 l! 






91 




26 



The whole number of females was 9, of whom 3 died. 

Of the minor operations upon the lower extremity, during the same pe- 
riod of time, the following is a statement. There have been two partial 
amputations of the foot, through the ( articulation of the tarsus, and two 
through the metatarsal bones. In one of the latter cases, amputation through 
the whole five metatarsal bones was performed. In another, it was done 
through the first metatarsal bone. Disarticulation of the great toe was 
performed in thirteen instances; and amputation through one of the pha- 
langes in two instances; of which operations in the great toe, ten were for 
frost-bites, and the others for injuries of various kinds. Disarticulation of 
one of the lesser toes in six instances, and through the phalanges in four; 
of which seven were for frost-bites, and three for injuries of various kinds. 

Upon the upper extremity, amputation at the first carpo-metacarpal ar- 
ticulation in two instances, and, in one instance, the second and third; in 
another, the third and fourth; in another, the third, fourth and fifth; and 
in another, the fifth metacarpal bones were removed at this articulation. 
The thumb was amputated at the metacarpo-phalangeal articulation, in five 
instances; through the first phalanx in one, and at the phalangeal articula- 
tion in one instance. One patient had amputation performed through three 
of the metacarpal bones of the fingers ; another, through two, and three 
others, each through one of those bones. Amputation of the finger was 
performed at the metacarpo-phalangeal articulation in twenty instances; 
through the first phalanx in one instance ; at the first phalangeal articula- 
iation in five instances ; through the second phalanx in one ; at the second 
phalangeal articulation in five instances, and through the last phalanx in 
one instance. Seventeen of these operations were for gun-shot wounds. 
None of the minor operations, upon either extremity, proved fatal. 

Such being the facts in regard to the mortality of these operations, a 
word concerning the causes which have produced it. Mr. Phillips attri- 
butes the increased mortality in the city of London to the greater number 
of rail-road accidents that have happened within a few years past, and the 
same cause has undoubtedly produced a similar effect here. It will be 



1848.] Buel, Statistics of Amputations in N. York Hospital. 41 



readily admitted, that this class of accidents presents some of the most for- 
midable, or even desperate cases in which amputation is ever demanded. 
In these cases the injury on account of which the operation is indicated, is 
most commonly attended with others of a serious character. Such patients, 
also, are not only very frequently without surgical attendance for many 
hours, and even for days, but are subjected to the additional hazard of trans- 
portation from a very considerable distance. Under this head might also be 
included a similar, and not uncommon class of accidents occurring at the 
landings of ferries. Making a distinct class of these injuries, it will be 
found that thirteen of the capital amputations above mentioned, were the 
result of such casualties, and no less than six of them unsuccessful. 

Another class of accidents, which presents equally desperate cases, is 
that of extensive burns. Every one is aware of the great mortality which 
attends these accidents, where a great extent of surface is involved. Six 
amputations were performed for this cause. Two of the patients were 
males, and four were females; of which number three females died. Here, 
then, are two classes of amputations, in each of which, the mortality is 
nearly fifty per cent. 

Two patients died of phthisis, after amputation of the forearm had been 
performed, for scrofulous disease of long standing. Two patients died of 
tetanus, one upon the ninth, and the other upon the seventh day, after am- 
putation at the shoulder joint. 

Four amputations were performed for malignant disease ; of this number, 
three were so far cured, as to leave the hospital with a fair chance of re- 
prieve for some time longer. One case was fatal; the disease in that 
instance attacking the lungs after the patient had so far recovered from the 
amputation, as to be up, and about his ward. In the successful cases, the 
recovery seems to have been very rapid. 

Fourteen amputations of the thigh were performed for disease of the 
knee-joint. Only two of these cases were fatal; the patients in both in- 
stances, being black men. Including those just mentioned, four of the 
patients operated upon were blacks, and of these, three died ; — a fact which, 
so far as it goes, tends to corroborate the common impression that amputa- 
tion, or any severe operation, is not as well borne by blacks, as by whites. 

By far the most common cause of the minor operations upon the upper 
extremity, was gunshot wounds, and upon the lower extremity, exposure 
to cold. 

On the whole, then, though the mortality after capital operations of this 
class appears at first sight very great, it is impossible to avoid the conclu- 
sion that this result occurs rather in spite, than on account, of the opera- 
tion itself. To adopt a contrary opinion, would be as rational as to con- 
demn any agent in the materia medica proper, on account of the mortality 
which might happen, at any period after its administration. 

The results obtained above, are similar in character to those presented 



42 Buel, Statistics of Amputations in N. York Hospital. [July 



by Drs. Norris and Hayward, in their respective papers upon this subject. 
In some particulars, they are less favourable than theirs, in others more so; 
accurate estimates, however, can only be formed from a large number of 

cases. 

It would have been interesting, if those gentlemen had made separate 
classes of the amputations at the different joints, so as to show their com- 
parative danger. 

The very great mortality attending this class of operations in the Parisian 
hospitals, renders such information particularly desirable. Dr. Norris, how- 
ever, mentions seven amputations "at the joints," of which four were 
cured, and three died. He has given a record of eighty amputations per- 
formed upon seventy-nine patients during ten years ; while Dr. Hayward 
has reported seventy amputations performed upon sixty-seven patients dur- 
ing about eighteen years. So that we have an aggregate of two hundred 
and forty-one operations performed on two hundred and thirty-seven pa- 
tients in civil hospitals in the United States, and under circumstances as 
nearly similar as we could expect to obtain. A brief summary of these 
data with regard to two or three of the more important points, is herewith 
presented. 





Philadelphia. 


Boston. 


N. York. 


Total. 


Whole number 


79 


67 


91 


237 


Cured 


57 


52 , 


65 


174 


Mortality per cent. 


27.84 


22.38 


28.57' 


26.58 


Upper extremity 


32 


10 


33 


75 


Cured 


27 


9 


26 


62 


Mortality 


15.62 


10. 


21.21 


12.73 


Lower extremity 


47 


57 


60 


164 


Cured 


31- 


43 


41 


115 


Mortality 


34.04 


24.55 


31.66 


29.87 


For chronic disease 


25 


45 


29 


99 


Cured 


21 


39 


23- J^V 


83 


Mortality 


16. 


13.33 


20.68 


16.16 


For injuries 


54 


22 


62 


138 


Cured 


37 


12 


43 


92 


Mortality 


31.48 


45.45 


30.64 


33.33 



In the foregoing table, it will be seen that the numbers given, are those of 
the patients operated upon. The comparison might be extended to other 
points, but it is unnecessary to do so at this time. 

The results here shown, are not discreditable to American surgery, as 
compared with European. Mr. Phillips gives the following, as a statement 
of the cases collected by him. 

In France 203 cases 47 deaths, or 23.10 per cent. 

In Germany 109 " 26 " 23.85 " 

In America 95 <* 24 " 25.26 " 

In Gr<*at Britain 233 " 54 " 22.66 « 



1848.] 



Lavender on Congestive Fever. 



43 



These statistics were obtained from a great variety of sources, by Mr. 
Phillips. He does not particularize the sources of his information with re- 
gard to America. Those in Great Britain were " drawn from a large num- 
ber of hospitals, and from the private practice of hospital surgeons, selec- 
tions being made, so as to render the result shown, a fair representation of 
what actually occurs." 

Looking at single places, we find that, 

For London, the cases amount to 107, and the deaths to 28, or 26.16 
per cent.* 

For Paris, according to M. Malgaigne, the cases amount to 560, the 
deaths to 299, or 53.39 per cent. 

For three of our principal cities as given above, the cases amount to 237, 
the deaths to 53, or 26.58 per cent. 



. Art. III. — Thoughts and Observations on Congestive Fever, By 
Charles £. Lavender, M.D., of Selma, Alabama. 

In the following remarks, it is my purpose to be brief and practical ; to 
avoid, as far as possible, theoretical disquisition, and to confine myself 
mainly, to such facts as have come under my own observation. By con- 
gestive fever is understood that form of autumnal disease, wherein the vital 
force is depressed, by the influence of miasmatic poison, below the point of 
successful reaction. In consequence of this depression of vital force, the 
heart is unable to give due circulation to the blood, which consequently 
becomes congested in the internal organs, and large venous trunks. If the 
vital energies do not fail in the onset, each succeeding paroxysm adds to 
this venous congestion, while the struggles of the heart grow fainter and 
fainter, till they cease altogether, unless, aided by the vigorous reaction of 
a powerful constitution, or by the use of effective remedies, it is aroused to 
an effort of such power and continuance, as to resist, and finally to over- 
come, the downward tendency. 

This nomenclature may be significant enough, yet it is by no means free 
from objection. It sometimes happens that the patient dies in the first 
paroxysm, without any febris at all. At other times, there is a chill or cold 
stage followed by a state of comparative repose, but little or no reaction, to 
be succeeded by another and fatal cold stage. Venous congestion also 
doubtless exists in other forms of fever. This congestion, however, so far 

* The apparent discrepancy between the statistics here given, and those of Mr. Phil- 
lips before given, results from the fact that, in presenting the general result, he has not 
confined his attention to the,city of London, nor indeed to hospital practice. 



44 



Lavender on Congestive Fever. [July 



from being the seat, or proximate cause of the disease in question, is but an 
effect of the action of the poison upon the brain and nervous centres. A 
similar pathological condition may be superinduced by concussion, or other 
injury done to the brain. It is but a symptom of congestive fever. And 
could we with equal clearness see the workings of the cerebro-spinal and 
nervous systems, the motions and uses of their fluids, the degree of their 
intensity, the momentum with which they circulate, and the obstructions 
which they encounter, we could then advance another, and more satisfac- 
tory step in the investigation of this, as well as other forms of disease. 
These more obscure, yet vastly more important, vital and pathological 
phenomena have, unfortunately, been overlooked by many able pathologists, 
in their researches on the liver and venous congestion. Too much im- 
portance has doubtless been attached to the circulation of the blood, to the 
neglect of the nervous functions. The symptom has been elaborately in- 
vestigated, while the cause has received comparatively little attention. 

A case that has assumed, and for some paroxysms maintained, the cha- 
racter of remittent or intermittent, may suddenly put on a congestive type. 
An attack, which at first assumed a congestive form, may, after a success- 
ful effort at reaction, wear the face of remittent or intermittent, of a mild 
character. 

Many cases in their onset and progress, wear the livery of all three of 
these types ; and might, at different stages, be set down under each of 
these heads. And sometimes, it would be no easy matter to decide upon 
the class to which a case properly belongs. 

These facts clearly prove congestive fever to be, not a disease sui gene- 
ris, but a form or modification, and that, too, the most violent and alarming, 
of the effects of miasmatic poison. It should be remembered, however, 
that congestive cases bear no fixed relative proportion to the number of au- 
tumnal fevers. It often happens, that a season passes by with but few 
well-marked cases of congestive fever, although bilious remittent and inter- 
mittent fevers prevail extensively. Such was the case, according to my 
observation, in the years 1832 and '34, in the valley of the Alabama river. 
At other times, the number of cases may be comparatively small, but the 
fever of a decidedly congestive type. Such was the case in the years 
1835 and '36, when congestive fever first invaded this valley as an ende- 
mic. The years '40 and '41 were similarly marked ; the former, which 
was extremely wet, being very sickly, with but few malignant cases ; the 
latter, which was not so wet, but very hot, not so sickly, but with many more 
fatal cases. Since that time, no year has passed without congestive fever. 
It never appears early in the season ; rarely before the first of August. 
The hotter and dryer, the earlier. It continues till after frost. 

These facts would indicate that there is some constitutional peculiarity 
in this miasmatic poison, or in the electric state of the atmosphere, caused 



1848.] 



Lavender on Congestive Fever. 



45 



perhaps by long-continued and excessive heat, which gives type and cha- 
racter to the prevailing fevers of the season. 

In its premonitories and its access, congestive fever presents but little to 
distinguish it from an ordinary attack of intermittent. There are mo?* lan- 
guor, more restlessness, and more debility. It is rarely the case that it 
makes its attack without a day or two of the ordinary premonitories of au- 
tumnal fever. It then approaches in the form of a chill. The patient is 
restless, and very much oppressed; skin pale and shriveled; extremities 
cold; features contracted; lips purple; tongue pointed, and of a leaden 
hue, or pale, cold and clammy; pulse feeble, quick, frequent, irregular, 
and intermitting; tendons corded ; occasional rigors, and sometimes shaking 
chills, though the patient rarely complains of coldness. There is no acute 
pain, but a dull heavy aching in the head, back and limbs. Usually there 
is great thirst, with nausea and vomiting, but these symptoms are not 
always present. In place of febrile reaction, the surface grows colder, and 
is bedewed with a cold unnatural perspiration. There is an indescribable 
sense of restlessness and oppression, the patient remaining but a few seconds 
in any one position ; on rising to his feet, he becomes giddy, staggers, and 
perhaps falls. He writhes under tormenting heat, calls for ice, desires to 
be fanned constantly, and to have cold water sprinkled on his face and 
breast, while his skin is as cold as the marble wet with the morning dew. 
In some cases, however, there is much morbid heat about the head and 
chest. A copious sweat suddenly breaks out, and as suddenly disappears; 
skin becomes motley and bluish, its sensibility impaired, impress of fingers 
remains some seconds after pressure is removed; sometimes ecchymosis in 
dependent parts; respiration irregular, with frequent sighing; great anx- 
iety, countenance haggard; eyes suffused ; a watery purging is sometimes 
a dangerous symptom, and hiccough a troublesome attendant. There is 
usually a most distressing sense of sinking down, and, to the patient him- 
self, a most alarming incubus, or feeling of suffocation ; he lies still, it may 
be for a minute, without breathing, then gasps for breath, makes short and 
hurried respiration; cries out that he shall die for want of breath; rises, 
advances hurriedly to the window, staggers, throws himself on another 
bed, or falls on the floor ; the pulse has ceased to flutter at the wrist ; a 
moment's unusual anguish, a gasp or two for breath, the heart ceases to 
beat, and death closes the scene in six or eight hours from the access, the 
sufferer retaining his senses to the last. At other times, death approaches 
under cover of a deep comatose sleep, of several hours' duration. Some- 
times, though rarely, the paroxysm closes in convulsions. 

The fatal moment is sometimes delayed a few hours by the free use of 
diffusible stimulants, in which case the patient usually dies comatose. At 
other times, partial reaction takes place; the skinbecomes warm or even hot; 
extremities remaining cold ; pulse may again be counted; from 150 it falls 
to 120; it may be the patient sleeps for some hours, or dozes on in painful 
No. XXXI.— July, 1848. 4 



46 



Lavender on Congestive Fever. 



[July 



and interrupted slumbers, to be followed the next twenty-four hours by an- 
other paroxysm, terminating in fatal collapse. 

It must not be supposed that all cases of congestive fever are alike ma- 
lignant, or marked by the same alarming symptoms and fatal results. 
Perfect reaction may terminate the first paroxysm in rapid convalescence. 
Partial reaction may take place ; the next paroxysm may be less violent, and 
of shorter duration; this may be followed by reaction still more complete, 
and so on, till perfect innervation is restored, all the congested blood in the 
system put in motion, all the organs disengorged, with equalization of tem- 
perature, and of nervous energy ; or the disease may run into well-marked 
remittent or intermittent. But most commonly, under proper treatment, 
complete reaction follows the first paroxysm ; morbid action is then broken 
up, congestion removed, innervation restored, and the patient recovers 
rapidly. 

There is scarcely an important organ which may not, during the pro- 
gress of the disease, become the seat of local congestion. The spleen may 
become engorged to such an extent in a few hours, as to be found double 
its natural size. The same, to a less extent, may be said of the liver. 
Congestion of the lungs is an alarming occurrence, which doubtless always 
exists, to a greater or less extent, in this form of fever. The great oppres- 
sion, laborious breathing, heaving of the chest, and sense of suffocation and 
sinking down, denote such a state. But of all the local congestions that 
attend upon this form of disease, that of the brain is most alarming, least 
manageable, and most fatal. It is marked by deep coma, low muttering 
delirium, rplling of the head on the pillow, a drawing of the head back- 
wards, dilatation of pupils, optic illusions; and if partial reaction takes 
place, raging delirium may come on. 

Unfortunately for young practitioners at the South, their knowledge of 
this formidable disease is chiefly drawn from the well studied lectures of 
professors who never met with it in practice, or from the ponderous 
volumes of writers on general therapeutics, to whom congestive fever is a 
matter of history. The most unwelcome, and perhaps the most useful, les- 
son that such a practitioner ever learns, is taught him by the first well- 
marked cases of this type with which he meets. 

That the character of the disease in question, as it makes its appearance 
in this latitude, may be properly apprehended, I introduce a few cases 
from my note book, which terminated fatally, without treatment. 

Case I. — B. D., aatat. 16, good health and temperament; experienced a 
light chill 3d Sept. '41; little reaction; copious perspiration; restless, 
and very much oppressed. 

4th. Somewhat languid, but no particular complaint. 

&thi Cold stage at 8 A.M.; shivering at intervals, alternating with 
flashes of heat, for two hours; extremely restless and oppressed ; could not 
be confined in bed; would rise, stagger, and sometimes fall; surface very 



1848.] 



Lavender on Congestive Fever. 



47 



cold, but complained of much heat. At 12 o'clock, without febrile reaction ; 
profuse perspiration ; at first warm about the head and chest, but soon be- 
coming cold and icy; confusion of intellect; optic illusions; twitching of 
tendons. In less than an hour, watery purging ; low delirium. When I 
saw him at 3 P.M., he was dying convulsed. 

Case II. — P. D., setat. 14, brother to the above ; a sprightly boy, of good 
temperament, was attacked on the 7th Sept., two days after the death of his 
brother ; some chilliness, followed by deep sleep and copious sweat, but 
little, if any, fever; restless night. 

8th. Walked about the farm ; insisted he was well ; took no medicine. 

9th. Rose early, dressed, and went out. Came in at seven, with a chill ; 
threw himself on the floor, and went to sleep. In an hour, was sweating 
profusely ; in another was cold, and could not be waked. At 9, his mother 
became alarmed, and sent for me. When I arrived at 12, the boy had 
been dead one hour. Although the surface was cold and clammy when he 
died, two hours afterwards it was dry and of natural warmth. Even the 
extremities, tips of the nose and ears were warm, and the countenance 
natural in appearance. 

Case III. — Mr. K. a labouring man, aged 38, 24th July '41, felt some 
indisposition, restlessness, with sense of impending danger; some rigors, 
with hot flashes, but no fever. 

2oth. Somewhat indisposed, but rode four miles to mill, and returned in 
the afternoon. Passed a very uncomfortable night, tossing in bed, and la- 
bouring for breath; at times rising and going to the door ; surface cold, but 
complaining of internal heat. 

26th. Felt somewhat better in the morning ; but soon the distressing 
symptoms returned, with increased force. Some shuddering at first ; soon 
became cold, but would not be covered ; nor remain long in bed ; on rising, 
would reel, with sense of falling forward; complained of great heat, and 
went from bed to bed, in search of a cooler place ; drank often of cold 
water, no relief ; occasional emesis ; cold sweat. When I saw him at 2 
P. M., the whole surface was of that peculiar icy coldness, painful to the 
touch, and damp with clammy sweat ; skin pale and shriveled ; features 
shrunken and cadaverous ; countenance unnatural, and marked with deep 
distress; pulse gone from the wrist; heart fluttering rapidly, but feebly ; 
tongue pointed, pale, and cold ; breathing laboured, interrupted, and greatly 
oppressed ; breath cold ; complained of 44 burning up ;" that he should 
44 die for want of breath ;" would not remain half a minute in one position, 
nor suffer the lightest covering ; rose rapidly from bed, staggered to the 
door, and returned as hastily to bed; spoke rationally; no appearance of 
delirium. Took quin., camph., ammon., &c. ; no perceptible effect. About 
3, rose hastily ; said he should die if he did not get fresh air; lay down on 
the-floor, remained quietly on his side for a few seconds, perhaps without 
breathing; turned on bis back, exclaimed 44 I'm gone," and breathed no 
more. 

Cases like these, terminating fatally on the third day, or in the first well- 
marked paroxysm, often occur, during a season in which 44 congestive 
chills" prevail. 

Treatment. — In order to arrest a disease like this, tending with such 
fearful rapidity to a fatal termination, the most prompt, vigorous, and well- 



48 



Lavender on Congestive Fever. 



[July 



directed treatment is necessary. In this, above all other diseases of a gene- 
ral character, time is of the most vital importance. One hour's indecision 
may prove fatal. With the first three or four hours after the case becomes 
alarming, all may be lost. And yet, when properly treated, there is no 
disease to which the physician, who loves his profession, can point with, 
prouder satisfaction. 

Blood-letting, which is always a most hazardous operation in this form of 
disease, if resorted to at all, should be accompanied by the most powerful 
internal and external stimulants. Brandy, quinine, camphor internally, 
sinapisms to the spine and epigastrium, and hot applications to the ex- 
tremities, while a small orifice is made, as I prefer, in the external jugular 
vein. As the blood runs slowly, the finger should be placed upon the 
pulse, and its changes carefully noted. If it waver, become more feeble, 
frequent or intermitting, the vein should be instantly closed. If the pulse 
increase in force or volume, and not in frequency, the bleeding being ser- 
viceable, may be carried to considerable extent. Even then it is more safe 
to bleed very moderately, and to repeat in an hour or two, if thought ad- 
visable, than to make a large bleeding at once. For it will sometimes 
happen that the pulse maintains its force and volume through the operation, 
and even for some time afterwards, and then suddenly sinks, perhaps to 
rise nq.more. 

In case second, two hours after death, I found the jugulars very much 
distended, one of which was opened, and a pint of black blood discharged. 
This blood was evidently regurgitated, and was with difficulty restrained 
by means of an adhesive strip, the urgency of my engagements at the time* 
preventing a more extended observation. On the following day, occurred 

Case IV.— H. S., eetat. 18, after a day or two of the usual premonitories, 
at 10 A. M., Sept. 10th, 1841, became cold, restless, oppressed, with occa- 
sional rigors; could not be confined to his room; lay a few minutes in one 
bed, and then hurried to another. Extremities cold to the body, but some 
morbid heat about the head and chest. Was put into the warm bath, 
fainted, and was with some difficulty restored. Saw him at 6 P. M. Pulse 
barely perceptible at the wrist, 150, deep seated, thready and intermitting; 
skin very cold, but much complaint of heat, and sense of suffocation ; fre- 
quent -sighing, and interrupted respiration; remains but a minute in one 
position, and will not be covered; some watery purging; countenance 
pale, shriveled, and anxious; eyes suffused and watery; intellect good. 
Ordered, immediately, brandy, camph. and laud., with frictions of dry 
mustard. Was preparing sinapisms, when the attendants cried out " he 
is dead." On approaching the bed, found him motionless and pulseless; 
breathing had ceased, and no motion could be felt over the region of the 
heart; jugulars much distended. With the case of the da}' - before fresh in 
my mind, I instantly opened a jugular vein, which bled freely. In about 
one minute after the blood began to flow, the patient breathed, and the 
pulsations of the heart were again manifest. Sinapisms, lotions, frictions. 
Brandy and water, almost thickened with quinine and camphor, thrown 
into the stomach. In ten minutes he breathed freely, and swallowed with- 



1848.] 



Lavender on Congestive Fever. 



49 



out difficulty. In twenty minutes, he spoke rationally, and took readily 
whatever was offered to him; pulse could he counted at the wrist, 150. For 
some hours he rested well, and hopes were entertained of successful re- 
action. He sunk eight hours after the bleeding. 

Case V. — Sancho, a coloured man, aetat. 35, taken on the 4th Sept. '42, 
without any premonitory symptoms, and soon sunk into collapse. Saw him 
at 10 P. M., 8 hours after access. Insensible ; low muttering delirium, 
and rolling on the floor, but now quiet ; eyes fixed ; pulse a mere flutter ; 
breathing laborious and rattling; supposed to be dying. 

The brain appearing to be the seat of congestion, he having been insen- 
sible from the access, opened a temporal artery ; bled imperfectly; opened 
a jugular; bled freely, at intervals, for an hour or two, with marked im- 
provement of symptoms — about f^xx ; rubbed all over with spts. capsi- 
cum and mustard ; cold dash to head, sinapisms to feet ; stim. enemata ; 
spts. quin., camph. liberally. In the course of 12 hours, one drachm calo- 
mel had established free secretion from the liver and bowels; reaction took 
place ; a common remittent followed, which yielded to ordinary remedies. 

Although a few cases like the above, have induced me favourably to 
regard bleeding from the jugular vein, in desperate cases of congestive- 
fever, or in which congestion of the brain exists, yet am I compelled to 
regard the use of the lancet, in this malignant form of miasmatic disease, 
as a most hazardous and often fatal practice. 

During the progress of reaction from a congestive chill, inflammation of 
the stomach, liver, or other important organ, sometimes makes its appear- 
ance, accompanied by fever of high excitement, as a sequela of the en- 
gorgement of these organs. Such cases may require topical, and if the 
inflammatory symptoms run high, general blood-letting. But while the 
distinctive symptoms of congestion remain, while there are great restlessness 
and oppression, quick, intermitting or compressible pulse, laborious breath- 
ing, especially if there is no congestion of the brain — the lancet should not, 
for a moment, be thought of. Even where the symptoms have, in a measure, 
given way, and reaction been partially established; when the heat becomes 
equalized, oppression alleviated, pulse full, and slightly resisting — even 
then, a small bleeding may, and a large one will, almost inevitably, bring 
on a rapid and fatal collapse. 

There is yet another condition that deserves marked attention, because 
it is so likely to betray the young practitioner into the use of the lancet. 
It is when a congestive attack has yielded to the influence of quinine ; 
reaction appears to be complete, natural temperature is restored to the 
surface, pulse becomes full and flowing, with a peculiar swell under the 
finger, and slight sensation of resistance. At the same time there is a 
feeling of restlessness and apprehension ; dull headache, with fullness of 
superficial veins. The patient complains of oppression, and often requests 
to be bled. Open a vein, and the blood flows freely, looks dark and thick. 
When eight or twelve ounces have been drawn, the bleeding suddenly 



50 



Lavender on Congestive Fever. 



[July 



stops, the venous fullness has left the surface, which becomes pale and 
shrunken ; the pulse quick and thread-like ; an indescribable sense of 
sinking comes over the patient ; he cannot be controlled, but tosses in bed, 
or rises to his feet and falls. In a few hours death closes the scene. At 
other times you may bleed freely, in such cases as the above, with re- 
lief to the head, and no perceptible ill effects for one or two hours after 
the bleeding, and when you begin to congratulate yourself upon your suc- 
cess, the patient becomes faint, nausea and vomiting follow, and a few 
hours may close the scene. 

In this latitude, fevers of any kind do not bear the lancet well. Con- 
gestive fever does not make its appearance till the system is greatly weak- 
ened by long-continued and excessive heat. When it has made its attack, 
the vital force is very much exhausted, and the patient is fast falling into 
collapse. In such a case as this, I would earnestly say to my young pro- 
fessional brethren — Beware of the lancet! Be assured, without proving by 
sad experience, that the lancet, instead of being " the anchor of hope," is, 
emphatically, the sickle of death in congestive fever. 

Emetics are decidedly hurtful in congestive fever, unless it be to unload 
the stomach at the onset, and this nature rarely leaves for the physician 
to do. When necessary, mustard, or ipecacuanha in an infusion of capsi- 
cum, is to be preferred. In most cases, irritability of stomach is a most 
troublesome symptom, which emetics tend to excite and to aggravate, ra- 
ther than to allay. Nothing, perhaps, except the lancet, is more effectual 
in driving into hopeless collapse a case of congestive fever than an eme- 
tic, and especially an antimonial one. 

Cathartics of a drastic or hydragogue character, are scarcely less objec- 
tionable than emetics. The very worst consequences may always be ex- 
pected from their use. Collapse, fatal, if not speedily remedied, is often 
the consequence of an active cathartic. This fact, and the treatment ne- 
cessary to insure reaction, may be more clearly illustrated by an example. 

Case YI. — Mr. L., planter, set. 40, had chilis, followed by some fever; 
with dull headache, inability to walk without reeling, and sense of falling 
forward. Before the third paroxysm, took a dose of jalap and crem. tart., 
which operated copiously. In a few hours, chill came on ; no reaction ; 
purging still continued. Spent a restless night. 

Sept. 19/A, 1842. Saw him at 9 A. M., day after the cathartic. Cathar- 
sis still continued; surface cold and damp as marble in the morning dew, 
yet complaining of intolerable heat; pulseless at wrist; great anxiety; 
cannot rest a minute in any position ; will not suffer the lightest covering; 
great thirst — drinks and rejects; delirious, pulling at the bed, and catching 
at the air; will not allow himself rubbed; tears off all applications; capil- 
laries congested; surface purple. 

Gave at once 40 drops of laudanum, 10 grs. sulph. quin., 2 grs. g. camph. 
in brandy and water. Cold affusions. Repeated the quin. and camph. in 
one hour, afterwards, every two hours. Catharsis and emesis ceased ; skin 



1848.] 



Lavender on Congestive Fever. 



51 



soon became warm, and resumed its proper colour; pulse returned to the 
wrist. In six hours, he was restored to his proper senses, and a calm sleep 
followed. He was kept fully under the influence of the quinine, about 2 
grs. per hour, for forty-eight hours, when a mild laxative of rhubarb and 
magnesia completed the treatment. No chill or fever followed. 

And yet, cathartics of a proper character are valuable in congestive fever, 
and in some cases indispensable. If the patient, after the first paroxysm, 
be put promptly under the influence of quinine, and so continued for forty- 
eight hours, or until the time for a second paroxysm has been passed in 
safety, a mild cathartic or two will complete the cure. Bat when two or 
three paroxysms have elapsed — when the viscera become engorged with 
blood, secretions vitiated or suppressed, tongue furred—in these cases^ 
more active cathartics are necessary. Everything, however, depends upon 
the character of the cathartic, and the manner of its operation. While a 
dose of active medicine, causing free watery purging, would, if uncon- 
trolled, be attended with dangerous, if not fatal consequences, that remedy 
which acts upon the liver in the production of dark, consistent bilious ope- 
rations, is full of hope. In the fulfilment of this important indication, no- 
thing is so much to be relied upon as a mercurial. Let this secretion be 
established by the use of calomel, or blue mass, and milder means, as 
rhubarb and magnesia, may be substituted. 

Quinine is fully proved by experience to be the great remedy, in all 
cases of marked periodicity, and emphatically so in Congestive chills. At 
what time it should be administered, is no longer a question. No time should 
be wasted in useless efforts to prepare the system for its reception. The 
patient should be put promptly under its influence, and continued under it 
until all fear of a congestive chill has passed. What quantity should be 
given is not now so important a question as it was once held to be. The 
effect is a vastly more important consideration than the amount of the re- 
medy necessary to secure that effect. Five grains will do as much in one 
case, as twenty in another. In the same case, five grains will effect as 
much at one time, as twenty grains at another time. Miasm is a poison 
that acts by depressing the vital force ; but as a given amount of miasm 
will not produce the same degree of prostration in all persons who are sub- 
jected to its influence, so will not the same dose of quinine be attended with 
similar results in all cases. The quantity must be proportioned to the sus- 
ceptibility of the nervous centres to be acted upon, the aptitude of the vital 
telegraph to convey the impression, and the venous and nervous congestion 
to be overcome. 

When a well-marked case of congestive fever, or one of a doubtful cha- 
racter, presents itself, five, ten, or, if it be an urgent case, twenty grains 
of quinine ought to be administered at once, and repeated every hour or 
two, till its characteristic effects are manifest. This being done, the pulse 
becomes more firm, and somewhat flowing, with a peculiar swell, regular, 



52 



Lavender on Congestive Fever. 



[July 



and twenty or thirty beats in the minute less frequent ; the tongue becomes 
moist, and less pointed; skin dry and warm, or, if there has been morbid 
heat, the surface becomes preternaturally cool, the intolerable inward heat 
and oppression greatly mitigated, headache and restlessness in a measure 
removed ; patient becomes calm, and perhaps sleeps. When the system 
comes fully under the influence of the remedy, its peculiar action on the 
brain is made known by a sense of fullness and ringing, or roaring, in the 
ears. This state of things being superinduced, two or three grains per 
hour, or four grains every four hours, will be sufficient, in. most cases, to 
guard the patient against another paroxysm. An hour or two, however, 
before the chill is anticipated, a larger dose should be administered. Much 
care ought to be taken that the effects of the remedy be not suffered to ex- 
pire, till all fear of a chill has passed. If general reaction be established, 
breathing free, circulation vigorous, sensorium undisturbed, little danger 
need be apprehended, for the case is safely under the control of the reme- 
dy. If the hour at which the previous chill occurred, be safely passed the 
following day, there is strong hope that no other paroxysm will follow. 
And if the same hour be passed the third day, in safety, that hope becomes 
confirmed. A mild cathartic, and a few more grains of quinine, will com- 
plete the cure. 

It sometimes happens that quinine causes an almost uncontrollable irri- 
tability of the stomach, and at other times, a very disagreeable fullness of 
the brain, and ringing in the ears, seeming to spend its force upon the brain, 
without influencing the circulation. In the former case, I usually add g 
gr. of morphium, and in the latter, a grain or two of ipecac. In cases where 
quinine seemed inadmissible, I have substituted, with happy consequences, 
a combination of camphor and opium, with a small portion of ipecac, in 
brandy, if the stomach will bear it. I seldom risk the case with a single 
remedy, but prefer the following combination: R. — S. quinin. grs. iv; g. 
camph. grs. ij; pulv. ipecac, gr. ss ; g. opi. gr. |, to be taken every two 
hours ; varying the proportions, of course, to suit the case. 

When taken in large doses, by a person in health, quinine increases the 
frequency of the pulse eight or ten beats in the minute, augments its vo- 
lume, and gives to it a peculiar and somewhat resisting swell, not readily 
mistaken by one accustomed to it. Give one or two grains to a man in 
open fever, and you add to the excitement, and sometimes bring on head- 
ache and slight delirium, as I have seen. Give ten grains in such case, and 
you allay febrile excitement, have a full, flowing, quinine pulse, cool, moist 
skin, sensorium clear, and no complaint of heat or thirst. This is one of 
the great peculiarities of this medicine. Give ten or twenty grains to a 
patient in congestive chill, or in that stage when a feeble effort is being made 
at reaction, and in an hour or two the pulse will be found lessened in fre- 
quency twenty or more beats in the minute, but much increased in force 



1848.] 



Lavender on Congestive Fever. 



53 



and volume ; with abatement of all the urgent symptoms. The good effects 
of a single dose will, sometimes be felt for twenty-four hours, or longer; and 
in some cases, no repetition of the remedy will be found necessary. In- 
stances similar to the following abound in my note-book. 

Case VII. — Dr. H., set. 35, full habit, good temperament, had been for 
some days labouring under remittent fever, which had assumed a congestive 
character. A crisis was approaching about 6 P. M. Had been taking 
calomel 20 grs., s. quin. 5 grs., g. camph. 2 grs., every two hours through 
the day, with no sensible effect; sinking hourly. Met his attending physi- 
cian, who had been with him all day, and who was so fully convinced that 
the patient must die, that he would not return with me. 

Found him, at 6 P. M., covered with a cold, clammy sweat; extremities 
cold to the body ; some morbid heat about the chest ; pulse a mere nutter, 
not to be counted; skin purple ; impression of the finger remains a minute 
or more; great restlessness; oppressed and laborious breathing; tongue 
furred, leaden colour, pointed and clammy ; intellect somewhat wandering. 
Mixed 20 grs. quin. in half a tumbler of brandy and water. On being 
raised from his pillow, made a hasty and rather convulsive effort to swallow, 
spilled one-half, rejected what he had swallowed, and fell back, exhausted. 
Having in my hand another portion of twenty grains, put it into the tum- 
bler, which still held some grains of the first, and gave it all, with some 
difficulty, in cold water. 

In twenty minutes, the circulation was under the influence of the qui- 
nine, and the pulse, in a few hours, became distinct. For thirty-six hours, 
the peculiar effects of quinine, a swelling pulse, with tingling in the ears, 
continued, although not another grain was given. One hour after the qui- 
nine, the patient swallowed 100 grs. cal., which dose was repeated in three 
hours. Before morning, black bile was discharged freely, and the urgent 
symptoms gave way. Some days of fever, of a remittent type, followed, 
which yielded to the usual treatment. 

I am by no means persuaded that quinine is a harmless agent, and may 
be given, in almost any quantity, without producing hurtful consequences. 
When pushed too far, painful fullness of the brain, alarming sounds, and 
ringing in the ears, deafness, slight delirium, twitching of tendons and hic- 
cough, will be some of the consequences. Caution must, therefore, be ex- 
ercised, not to push this valuable remedy too far. Overwork the brain, 
and the vital powers may become exhausted by too long-continued and ex- 
cessive action. In this way, I have no doubt, frequently repeated heroic 
doses of quinine exhaust the vital powers, cause indirect debility, and thus 
hasten that very collapse which quinine, judiciously administered, is so well 
calculated to avert. 

In like manner, brandy, and other stimulants, though valuable in sup- 
porting the vital force, and preventing collapse, or in arousing the system 
from that state, and for such purposes, may be given in large quantities ; 
yet may they be pushed too far, or be continued too long, and thereby aid 
in producing that condition which they were intended to prevent. They 
are useful, and may be given liberally, while they act in harmony with the 

I 



54 



Lavender on Congestive Fever, 



[July 



system, quiet the stomach, soothe the brain, and invigorate the circulation. 
But if they cause nausea, pain in the stomach, headache, or symptoms of 
intoxication, they should be used more cautiously, or be discontinued al- 
together. A patient who may have borne a pint of brandy in twelve hours 
before reaction, may not bear an ounce afterwards. The same observation 
is applicable to quinine. Although twenty grains of the sulphate may 
have been taken, witl* the most decided benefit, in a case of collapse, or in 
a case of congestive chill threatening collapse, yet, when reaction has been 
established, one grain may be sufficient, and even that not always required, 
and sometimes hurtful. 

Calomel, as has been observed, is often useful, and sometimes indispen- 
sable. If, by the timely exhibition of quinine, congestion be broken up, 
and reaction fully restored at an early stage of the attack, little further treat- 
ment will be needed. But when reaction is incomplete, with vitiated or 
suspended secretions, calomel should be given, so as to act upon the secret- 
ing organs, and chiefly upon the liver. Let this action be made known by 
the appearance of dark vitiated bile; let it be continued by moderate doses 
of calomel, or rhubarb and blue mass, till the secretions become healthy, and 
the patient is safe. Let the vital force be sustained by the use of quinine, 
and if there be not congestion of the brain when the bile begins to flow, 
the danger is passed. At least, I never saw a case that did not, under such 
circumstances,, recover. The dose of calomel is to be decided by the ne- 
cessities of the case. In a majority of cases, 10 grs. every two or three 
hours will be sufficient. R. — Calomel grs. x; quin. grs. v; ipecac, gr. j; 
morph. gr. ? ; pil. hydrarg. q. s. Ft. pil. sum. quart, lis. 

In many cases, quinine cannot, for a moment, be retained on the sto- 
mach. Roll it in blue mass, and the difficulty is sometimes obviated. Ad- 
minister largely per enema. Draw a blister speedily, and dress it with 
quinine. The system may be brought under its influence, and the patient 
saved. 

But quinine, like all other remedies, will sometimes fail us. Twenty, 
forty, or one hundred grains may have been taken. Its action on the brain 
may be apparent. Strange sounds distract the ears. The patient may 
imagine himself in a thunder-storm, with lightnings flashing in his closed 
eyes, and burning in his brain, and still be sinking all the time. — 
The remedy, pushed too far, is doing mischief. Failing to counteract the 
disease, it has attacked the vital organs, and is prostrating still further the 
vital force. A grain of morphine will not give a moment's rest. Diffusi- 
ble stimuli only add fuel to the flame that burns within, and are immediately 
rejected. Rubefacients have been used till the skin is sore ; and the ca- 
pillary vessels congested till the surface is purple. The patient rolls from 
side to side, and throws his limbs in every direction; calls for ice or cold 
water, which is rejected as soon as swallowed ; calls upon the attendants 
to fan him, and to sprinkle water on his face, to save him from dying. 



1848.] 



Lavender on Congestive Fever. 



55 



What, under these alarming circumstances, is to be done ? I know of no- 
thing better — and the emergency has often presented itself to me, in all its 
fearful realities — I know of nothing better than large doses of calomel, re- 
peated every two hours till a decided impression is made ; accompanied, 
at the same time, with the cold dash, or cold affusions. The case, as sup- 
posed, though alarming, is not altogether hopeless. A large dose of calo- 
mel, when swallowed, will be retained. These doses do not, in such cases, 
purge actively. So soon as their influence is felt upon the system, the pa- 
tient becomes more quiet, complains less of heat ; while the surface becomes 
warmer, heat more generally diffused, pulse stronger and less frequent. 
Free hepatic secretion is concomitant with, or soon follows, this state of 
things. Much smaller doses, or milder means, may be sufficient to keep 
up this action. Let this be done, and, with ordinary prudence, the patient 
will recover. 

Ptyalism I do not regard with favour. Salivation will not arrest a con- 
gestive chill, as I have experienced in my own case. 

Rubefacients, sinapisms, lotions, spts. turpentine, should be promptly and 
perseveringly applied to spine, epigastrium and extremities. If the patient 
will suffer no applications, rub him well with dry mustard, or spirits and 
capsicum, or spts. turpentine. If he will lie on his back, apply a sinapism, 
or flannel roller wet with spts. turpentine, the full length of the spine. The 
following case may serve, among other purposes, to show the value of perse- 
vering in the use of external means. 

m Case VIII.— D. S., set* 8, cold stage, P. M., 8th Sept., 1841, followed by 
high excitement, which soon, and suddenly, ceased, and he became cold 
and pulseless. Stimulants were resorted to. 

9th. Saw him at 2 A.M., for the first time. Pulse thread-like and irre- 
gular, 130 to 140; tongue dry, pointed, leaden hue, red edges; delirium; 
muttering; distress ;. skin cold and clammy; some morbid heat in the 
head; great thirst ; rejects everything that is swallowed; remains but a 
few seconds in one position. On moving from side to back, or vice versa, 
breathes six or eight times, hurried, half-inspirations ; ceases to breathe 
from eight to twelve seconds, then draws a long inspiration, mutters, or 
calls out incoherently, and changes position. R. — Statim, cal. grs. xx. ; 
quin. grs. ij ; g. camph. gr. j. Sinapisms, frictions. — Calomel grs. v ; 
quin. gr. j ; camph. gr. ss ; carb. amnion, gr. ss ; 2 hs. 

4 P.M. Worse. Pulse fluttering, and too indistinct to be counted; sub, 
tend, singult. picking at the bedclothes, apparently moribund. Gave morph. 
gr. | in brandy. Rub him all over with hot medicated spirits, and spts. 
turpentine, and apply mustard poultices to extremities and epigastrium. 
R. — Cal. grs. xx ; ipecac, gr. j ; morph. gr. § ; mass, hydrarg. q. s. Ft. pil. 
sum. quart, hs. — Camph. quin., C. ammon., aa gr. i; sum. uterq. hora. 
Cold dash, and cold applications to head. Warm bath, fainted; restored with 
difficulty. 

10th. 8 A.M. Has not rested five minutes through the night. No improve- 
ment in any of the symptoms ; low delirium, mutters, and occasionally cries 
out. Cadaverous look and smell. Sponge him all over with the medicated 
spts., and envelop him bodily in a strong mustard poultice. Continue treat- 



56 



Lavender on Congestive Fever. 



ment. 6 P. M. Sleeping. Several discharges of black bile; feet warm, but 
hands and arms cold, though not so damp ; pulse 130, regular ; tongue moist ; 
respiration 30, regular. Slept one hour ; the first rest for as much as five 
minutes, for 48 hours. R . — Compound cal. pil. every 4 hs., and comp. quin. 
pil. every 2 hs. Continue poultice. 

Wth. 8 A. M. Rested. Slept 2 hours ; warm ; pulse 120, regular, more soft 
and full; tongue moist and furred ; slight ptyalism. Four free discharges 
of black bile. R. — Pil. rhei., chicken water, rice water. VZth, Much better. 
Dark bilious matter copious. Continue treat. Vdth. Convalescent. 

Anodynes are peculiarly serviceable in this form of fever. Opiates are 
best; and no article of this class can give more satisfaction than the salts 
of morphium. In easing pain, in quieting intolerable restlessness and anx- 
iety, in mitigating bodily and mental anguish, in superinducing temporary 
forgetfulness of suffering and danger, in soothing nervous irritability, in 
allaying spasm, and thereby removing impediments to reaction, and thus 
promoting secretion, morphium has no rival, and may justly be called 
"the divine remedy." A compound of ipecac, gr. j, s. morph. gr. given 
with calomel, promotes its action ; with quinine, it is peculiarly useful in 
obviating, or in mitigating the unpleasant effects of that remedy on the 
brain and nervous system. There are but few cases of congestive fever 
which are not, at some period of their progress, largely benefitted by the 
use of morphine. Where continued irritability of stomach exists, it may 
be introduced by enema, or used endermically. Care should be taken that 
an over-dose be not administered, in this way, as I have seen one grain, 
applied to a recently blistered surface, cause decidedly narcotic effects. 

Cool acidulated drinks, ice water, lumps of ice, juice of acid and sub- 
acid fruits, as lemons, oranges, pomegranates and grapes, are very useful 
in allaying thirst and mitigating internal heat. 

The Cold Bash, or cold bath, as a remedy in this fever, yet remains to 
be noticed. In miasmatic fevers of high excitement, especially where 
there is much determination to the head, there can be but little doubt of the 
good effects of the cold bath. But in fevers of a congestive type, where 
the extremities are cold, its propriety becomes more questionable. In these 
cases, I make the feelings of the patient my criterion. If I find morbid 
heat about the head and chest— if cool drinks are grateful to the stomach, 
and cold applications cause a pleasant sensation, I use the cold bath or cold 
effusions freely. But' where they cause, as they sometimes do, a disagree- 
able chilly feeling, I continue hot applications and frictions. 

Having decided upon the use of the cold bath, if the patient is able to 
sit up, he is placed over a large vessel, with his feet in water as hot as he 
can well bear it, and cold water poured freely over his body, till he com- 
plains of feeling cool. If not able to sit up, he is placed on a mattress, or 
on thick blankets, warm applications are made to his feet, and cold water 
poured freely and steadily over his body for five minutes or more. Nothing 
can be more refreshing. On being replaced in dry sheets, he rests more 



1848.] 



Lavender on Congestive Fever. 



57 



quietly, and sometimes sleeps; perhaps a healthful glow appears on the 
surface, and his condition is favourable for the action of medicine. In ob- 
stinate cases, to secure the good effects of the cold bath, it must be frequently 
repeated ; or the patient may be for some time enveloped in sheets wrung 
out of cold water. 

Case IX. — Mary J., set. 14, bilious-nervous temperment, after some days 
of languor and oppression, with some chilliness, was attacked on the 7th 
Aug. '47; cold, but complained of great heat. Dark green matter by ca- 
tharsis, yellow by emesis. Was raised in bed, fainted, and continued ex- 
tremely faint, and much oppressed in breathing, with nausea, 
i 5 o'clock P. M. Pulse thread-like, one hundred and eighty to the minute, 
at times not to be felt at the wrist; tongue clammy, leaden centre, pale 
edges ; skin cold and damp ; complains of heat ; frequent rolling of head 
and tossing of limbs ; dullness of seeing and hearing; intellect dull. R.' — 
Statim,s. quin. grs. v; s. morph. gr. | ; g. camph. gr. j; frictions, sina- 
pisms. R. — Quin. grs. iv; camp. gr. j, every hour; cal. grs. iv; ipecac, 
gr. j ; morph. gr. |, every 4 hours. 

bth. A. M. Passed a restless night. Pulse 160, otherwise as before ; no 
action on bowels; nausea subsided; tongue dry; skin soft and natural ; 
pupils dilated; dullness of senses and restlessness as before ; respiration 
oppressed and irregular — 4 to half inspirations, and then a full one, at 
which the patient opens her eyes wide, and changes position* R. — Quin. 
grs. v, camph. gr. i, every two hours. Calomel and camph. as before. 
Sinapisms, frictions. 

P. M. No marked alteration. Continue treatment. 

Ecchymosis in all the dependent surface, from head to foot. Back, thighs, 
&c, of dark blue ground, with black splotches covering near half the 
surface. Frictions, spts. turpentine, and ess. oils. 

9th. Passed a restless night. Slight delirium. No abatement or altera- 
tion worth noting. Continue treatment. P. M. Considerable excitement. 
Pulse of more force, but irregular, 144 ; breathing much oppressed. Skin 
dry and very hot — so much so as to be painful to the touch. Tongue and 
fauces dry, much thirst ; no action on bowels ; cannot rest two minutes in 
one position. Cold applications grateful. Cold bath, by placing the patient 
in sheets that had been dipped in cold spring water, and covering well with 
blankets ; hot applications to the feet ; considerable shock. At first, respi- 
ration short and interrupted; in ten minutes, patient became composed ; in 
fifteen minutes, slept calmly ; respiration regular and free, 22 ; pulse more 
distinct and regular, 120. Repeated affusions. Slept 30 minutes. Re- 
mained in bath 90 minutes. Complained of feeling cool ; surface still 
warm. Wiped with warm towels, and put in dry sheets. Felt more com- 
fortable, and rested better. R. — Cal.gr. x, spts. nitre. One hour after 
the bathing, perspiration general and warm. Rested tolerably well through 
the night. 

10th. Pulse 120, full and regular ; tongue moist; senses normal; some 
bilious stools — 5 through the day. R. — Quin. grs. iv, every 4 hours. Rhu- 
barb and magnesia in small doses. 

Mth. Slept two hours at a time through the night. Three stools of bilious 
character ; pulse 95, full and regular; skin warm and moist ; tongue nearly 
clean ; ecchymosis red, absorption going on. R. — Quin. grs. iv every G hs. 
magnes. nocte. 



58 Lavender on Congestive Fever. [July 

12th. Convalescent ; ecchymosis disappearing; soreness in the limbs, 
and along the large muscles ; secretions free and nearly normal. Conva- 
lescence rapid. No ptyalism. 

The cold dash in cases of collapse, and in congestive fever falling into 
that state, is a bolder practice. In such cases, it appears to act revulsively, 
through the capillary nerves, on the brain and ganglionic system, arousing 
them to renewed action, as in case of catalepsy. Be this as it may, I have 
often had recourse to its use, and have in no instance had cause to regret 
the practice. It aids powerfully in arousing capillary circulation, in equal- 
izing heat, in quenching the fire that burns within, and restoring warmth 
to the surface. I offer a case by way of illustration. 

Case X. Esther, a coloured woman, aged 35 ; chill 7th Aug. '40 ; little or 
no reaction ; great restlessness; copious sweat. As most of the family 
were down with fever, and not enough well to wait on the sick, no further 
note was taken of this woman, till I found her, on the 9th, collapsed, cold, 
clammy, pulseless, delirious, rolling on the floor ; tongue pale and pointed ; 
respiration hurried and laborious. Gave with some difficulty, twenty grains 
of quinine. Had her laid on boards, and ten gallons of cold spring water 
poured over her in about five minutes, then rolled in dry blankets. In half 
an hour, there were decided symptoms of reaction. In four hours, the 
quinine and cold dash were repeated ; in four hours more, warmth was re- 
stored to the surface ; pulse 108 ; resting well. R.— Q,uin. grs. iv ; camph. 
gr. j ; ipecac, gr. ss, m. sum. 2 hs. Kept the patient under the influence 
of the quinine for 48 hours, when a small dose of rhubarb and magnesia 
completed the treatment. No return of chill or fever. 

Whether or not the cold dash in such cases as the above, unaided and 
alone, would bring about successful reaction, must be decided by a bolder 
practitioner than I am, while I hold in my hand such a remedy as quinine. 
I have found nothing more effectual in arousing the circulation in cases of 
collapse ; for which purpose it may be again and again repeated. Espe- 
cially is the cold dash serviceable in cases attended with great irritability 
of stomach, or where quinine determines too powerfully to the brain, or 
where there is much morbid heat about the head and chest. In such cases, 
it acts more promptly, and perhaps more vigorously, than hot applications. 
Nor are they at all incompatible with each other. Nor is the cold dash in- 
compatible with the vigorous use of calomel. On the contrary, it promotes 
the action of that remedy, by bringing the system to a proper secreting 
point, and by sustaining the vital force, till the calomel has time to act. It 
was my intention to introduce some cases illustrative of the foregoing re- 
marks, but my essay has already reached the limit which I had prescribed 
to it. 

Selma, Ma,, April 1848. 



1848.] 



Sims on Trismus Nascentium. 



50 



Art. IV. — Fur the?' Observations on Trismus Nascentium, with Cases 
illustrating its Etiology and Treatment. By J. Marion Sims, M. D., 
of Montgomery, Ala. 

Since the publication of my first paper on this subject, (Amer. Journ. 
Med. Sci., April, 1846,) new facts and observations have developed new 
truths, and detected the errors into which I had fallen. They will show 
that some of my first positions are untenable. For instance, I said that a 
deficient ossification of the cranial bones was essential to the production of 
the disease. This 1 must recall; for, as a general rule, the very reverse 
is the fact. The deficient ossification alluded to, was not intended to 
be understood as a pathological condition, but simply the physiological 
state so necessary to a safe and easy parturition. 

Another point on which I was in error, is the "dorsal decubitus." I 
find that children may have trismus, and at the same time, be kept on a 
feather bed, and that, too, when they are laid upon (what mothers usually 
call) the side. 

The next error that I have to correct is in regard to "spinal hemorrhage." 
The sequel will show that, under certain circumstances, a child may die 
of trismus in its most aggravated form, and yet have no extravasation 
within the spine. 

But while these positions are admitted to be erroneous, there are others 
which are fully sustained by every fact that has fallen under my observation, 
viz: — That trismus nascentium is a disease of centric origin, depending upon 
a mechanical pressure exerted on the medulla oblongata, and its nerves ; that 
this pressure is the result, most generally, of an inward displacement of 
the occipital bone, often very perceptible, but sometimes so slight as to be 
detected with difficult)'-; that this displaced condition of the occiput is one 
of the fixed physiological laws of the parturient state ; that when it per- 
sists for any length of time after birth, it becomes a pathological condition, 
capable of producing all the symptoms characterizing ; trismus nascentium, 
which are instantly relieved, simply by rectifying this abnormal displace- 
ment, and thereby removing the pressure from the base of the brain. 

These are simple truths, mere corollaries, plainly deducible from facts 
which I shall now proceed to relate, throwing in occasionally some practical 
remarks, naturally suggested by individual cases, as proper to the elucida- 
tion of the subject generally. 

Case I. — Dr. Hogan, writing to the editors of the New Orleans Med. 
and Surg. Journ., July, 1846, p. 136, says, "I have met with a case of 
trismus nascentium at the sixth day, since Dr. Sims' paper was published 
in the Amer. Journ. Med. Sci. I found the child upon its back, ' with the 
occiput shoved in? spasms occurring upon the slightest noise or touch. It 
was in articulo mortis. I left it dying. I called too late in the afternoon 
to make a post-mortem examination." 

Case II. — For this case I am indebted to Mr. J. C. Duncan, of Illinois. 
I copy it from his letter bearing date " Bloomington, August 9th, 1846." 

" Four days since I received your pamphlet on trismus nascentium. The 
description of the disease immediately reminded me that the child of a near 
neighbour had been suffering under precisely the same symptoms for two 



60 



Sims on Trismus Nascentium. 



[July 



days past, and was then supposed to be dying. The attending physician 
had declared it to be inflammation of the brain, and that death must ensue". 
The child was fourteen days old. Mrs. D., after hearing a brief narration 
of the contents of your paper, hurried away to the sick room to examine 
the child's head. The child had lain on its back all its life. She raised 
it up and found that the back of the head had all sunk in. * * * * * 
The spasms had been more frequent for the last twelve hours — the mouth 
was closed tightly, and swallowing impossible — a change of position (on a 
nice soft pillow) was adopted. In four hours from this change, which was 
repeated from one side to the other every half hour, the head had regained, 
in a great measure, its shape — that night the child was able, although with 
difficulty, to take some sustenance — by morning the spasms had almost 
entirely ceased, and in eighteen hours the babe was at the mother's breast. 
It is now perfectly well." 

Mr. Duncan is not a medical man, but the facts of this case are not the 
less forcible. 

Case HL — Mr. Jas. S. Winters' child (male) was born on Saturday, 21st 
March, 1846, at 4 A. M. It was a fine hearty looking child, but seemed 
to be quite unwell — refused the breast from the first — was not able to open 
the jaws so as to take the nipple ; was restless, sleepless and fretful all the 
time, making a distressing moaning, with occasionally 44 a peculiar sort of 
unpleasant breathing." What little nourishment it was forced to take 
seemed to sicken it. The grandmother, feeling great uneasiness about the 
child, held it on her lap most of the day and nearly all night. Its moan- 
in gs and restlessness, w T hich she attributed to the colic, caused her to give 
it repeated doses of paragoric and catnip tea, but with no benefit. It ap- 
peared to be in a great deal of pain, and throughout Sunday she noticed 
that it had occasionally a little spasmodic quivering or jerking of the right 
arm and leg, but not of the left. The movements or spasms of the arm 
and leg were, as well as she could determine, synchronous. 

On Sunday evening, I saw the child. It was then thirty-six hours old. 
Had for several hours refused to swallow anything. The grandmother had 
it lying across her lap on its back, with the occiput lying on her left knee. 
After hearing a description of the symptoms, as above related, I examined 
the occiput, and found the right edge of it pushed under the corresponding 
part of the parietal bone, while the left was riding over its parietal neigh- 
bour. [I wish this fact to be remembered, for, in connection with others 
to be related, it assists very materially in pointing out the rationale of the 
diseased action.] The grandmother remembered that the child had never 
been laid on its side. Of course, I lost no time in placing it properly on 
its side on a pillow. In two hours it was perfectly free from all pain, dis- 
tress, moaning and jerking, and it rested finely all night. On the next 
morning (Monday), it was able to suck freely for the first time, and the 
right edge of the occiput, like that of the left, was occupying its proper 
relative position, exterior to the parietal. 

This child was born trismal. Its restlessness, sleeplessness, moanings, 
stridulous breathing, spasmodic choreal, jerkings of the arm and leg, its 
locked jaws and inability to suck (although there was no tonic rigidity), all 
go to establish it as a case of trismus: and there was an inward displace- 
ment of a portion of the occiput. Now all these symptoms were instantly 
arrested simply by rectifying the occipital displacement, and, that, too, with- 
out giving one drop of medicine. . 1 



1848.] 



Sims on Trismus Nascentium. 



61 



Case IV.— Wyatt Peters' child, female, born on Monday, 23d of March, 
1846. Nothing unusual in the labour, which was the second. From the 
very hour of its birth, it seemed to be affected with cold, as manifested by 
a "hoarseness," "wheezing," or "rattling in the throat," which has always 
been worse during sleep, and worse at night than in the day. The mother 
says that over and over again they have made it suck a " piece of fat raio 
bacon to clear the phlegm out of its throat," but to no purpose. With this 
exception, the child did pretty well for the first nine or ten days, when the 
mother was waked up about one o'clock in the morning, by its hard breath- 
ing, and then for the first time it refused to suck, or, rather, it could not 
open its mouth wide enough to take the nipple. Every attempt at nursing 
would excite a spasmodic closure of the lips, thus preventing the introduc- 
tion of the nipple. There was also great restlessness, with moaning and 
slight spasms, but no tonic rigidity. These paroxysms would come on 
every night near about the same hour, with more or less violence, and last 
usually three or four hours. I saw the child on the nineteenth day, for 
the first time. Its crying, which was attended with a spasmodic, croupy 
sort of cough, had always been peculiarly weak, hoarse and stifled. It 
had occasionally a sudden involuntary jerking of the hands towards the 
head (as if it were frightened), accompanied with a tight puckering of the 
mouth. Jaws could not be opened. It could not suck at all. [This 
inability to suck fs pathognomonic of the disease.] The mother made 
many fruitless efforts to force the nipple into the child's mouth, exciting 
invariably a spasmodic closure of the lips. A little tea seemed to strangle 
it ; indeed, it could not swallow, but with the greatest difficulty. Its breath- 
ing was hurried, stridulous. [What the mother called "stuffed or choked 
up with cold," " wheezing," "rattling in the throat," "hoarseness," I find 
to be a stridulous inspiration. Until I saw this case, I was not aware of 
what was to be understood by the graphic language used by mothers to 
designate this symptom ; for instance, in my former paper on this subject, 
I quote the words of one mother where she says that her child "made a 
little wheezing noise like a kitten." Another, " like it was choking to 
death;" and a third, where it made a noise " more like something a dy- 
ing," all evidently meaningwhat we understand by the term laryngismus.] 

When I entered the room, the mother was holding the child in her arms. 
It was lying on its back, the occiput resting exactly on her left arm. On 
inquiry, I found that it slept on a pile of pillows in a rocking chair during- 
the day, and in the bed with the mother at night. Without asking any 
more questions, I was determined to see in what position the child was 
kept, so I requested the mother to place it in the chair, as she was in the 
habit of doing during the day. She did so, and laid it on its back. I now 
directed her to take it up and put it to bed, just as she would do if she 
were going to rest for the night. She did so, and placed it exactly on its 
back again. She had always kept the child lying on its back, was afraid 
to turn it on the side, " for fear it might turn clear over on its face, and get 
smothered." 

The edges of the occiput were overlapped by those of the parietal bones, 
not to so great a degree as I have seen, but to a very remarkable extent : so 
much so that the parents could easily perceive it when it was pointed out 
and explained. I had the child placed properly on its side on a pillow, 
not giving any medicine. In twenty minutes (by the watch), the stridu- 
lous inspiration was gone ; and in thirty minutes, there was no moaning or 
other signs of uneasiness. I left the little patient at 10 o'clock, feeiiRg 
No. XXXI.— July, 1848. 5 



62 



Sims on Trismus Nascentium. 



[July 



pretty well satisfied that it would recover without any more trouble; but 
about midnight, (as usual,) it screamed out suddenly some three or four 
times in rapid succession, throwing the hands up, and clinching them so 
tightly, that they could not be opened ; at the same time that the head was 
jerked back, eyes rolled in every direction, the lids being kept widely 
open, jaw " fallen,*' feet and legs stretched out, body thrown backwards, 
and all attended with a sort of quivering motion thrilling the whole frame. 
These spells of clonic spasm (thus described almost in the mother's own 
language), would come on every two or three minutes, the paroxysms get- 
ting shorter, and the intervals longer, till they gradually disappeared about 

3 o'clock in the morning. During this period, the mother felt so uneasy 
about the child, that she took it up two or three times on its pillow, but 
finding every time she touched or moved it, that the " spells" got worse, 
and would come on oftener, she was constrained to let it lie still. About 

4 o'clock, it sucked a little, but very feebly, and fell asleep. At 6 o'clock, 
it waked up, and sucked very well, indeed, better than it had ever done 
before. From this time on, it was regularly convalescent, although the 
occiput did not gain its proper position exterior to the parietal bones for 
about 36 hours, during which time the child was kept carefully on one 
side or the other. After this, it was laid upon the back without disturbing 
the relative position of these bones, and without reproducing the slightest 
symptom of the disease. 

Case V. — This is one of the most remarkable cases that I have ever 
known. On Thursday, 2d of April, 1846, my friend Dr. Vickers was sent 
for to see a negro child at Robert T. Ashurst's, which had been sick more 
or less all its life. It was then between four and Jive months old. The 
doctor related the case to me, and I transcribed it nearly in his own words. 
I shall use the notes made at the time. He says: "It was a pale, puny, 
sickly looking,emaciated child; had frequent, involuntary, greenish mucous, 
griping passages. It was lying on its back in a deep, narrow cradle. Had 
a constant rotary movement of the head on the pillow as it lay on its 
back, exactly like what we see in hydrocephalic cases. It seemed to be 
clawing at its mouth with the right hand ; yet the hand was directed to no 
particular spot. By watching it awhile, I soon discovered that the motions 
of the right hand were involuntary, that it moved in a regular gyration 
from the mouth across the breast, down by the side, being now thrown out- 
wards and brought round again towards the mouth, and so on; each gyra- 
tion occupying a definite, almost unvarying period of time. In addition to 
this movement of the right hand, I observed a similar one of the right leg, 
which was altogether synchronous with that of the upper extremity. This 
consentaneous action in the right side naturally led me to notice the left, 
and I immediately saw that it was passive, indeed, perfectly paralyzed. I 
raised up the left hand; let it go, and it fell lifeless by the side. I now 
raised up the left leg, and let it go. It, too, fell, like a stick, powerless and 
motionless, and obeying most perfectly the laws of gravitation. Its eyelids 
were half open, eyes glazed and turned up, pulse almost imperceptible, 
stringy; one pulsation running so closely into another, as to make it im- 
possible to count them. Its breathing was panting, and very frequent. 
I really thought the child moribund. 

" It was lying on its back on a cradle, which was too short to allow it to 
lie its full length, and so narrow and deep, as to preclude the possibility of 
its turning on its side, even if it had had the physical power to do so. Its 



1848.] 



Sims on Trismus Nascentium. 



63 



bedding was composed of blankets, and it had an old pillow of chicken 
feathers under its head. The back of the head, and for half an inch around 
the lambdoidal edges of the parietal bones, was as clear of hair ' as the palm 
of my hand,' so smoothly had it been worn off by the constant rotary mo- 
tion of the head. The occipital bone was shoved in on the brain to an 
almost incredible extent. It was pushed so far under the level of the 
edges of the parietal bones, as to have the appearance of a segment of a 
sphere sawed off and placed on the inside. 

"I immediately determined to see whether all this train of symptoms 
(though I feared it was too late), was not the result, solely, of the dorsal 
decubitus, and occipital displacement; so I took the child up and placed 
it on its side in a bed, without giving it any medicine at all. In one hour, 
the spasmodic action of the right arm and leg began to subside ; and just 
in proportion as the chorea of the right side was relieved, so was the 
paralysis of the left. In two hours its pulse was full, strong, easily counted, 
and only 120 per minute. Its breathing was entirely relieved. After 
keeping the child about four hours on alternate sides, (seeing that it was 
now out of all danger,) I thought I would try the experiment of placing it 
again on its back in its little pillory, the cradle ; and, in less than five 
minutes, all the symptoms were reproduced, the chorea, paralysis, #c. 
Turning it upon the side soon put a stop to them. This experiment was 
repeated frequently with the same results. 

"It now occurred to me to try some experiments, with the view of observ- 
ing the symptoms of (properly speaking) a trismal character. The mother 
said, that there had always been great difficulty in getting the child to suck; 
that sometimes it could not draw the breast at all ; and very often would 
stop before it got half through; and that this had been the case from the 
time it was a Week old. I requested her to suckle it ; (it was now quiet ; 
had been for some time lying on its side.) She took it up from the bed, and 
applied it to the right breast. In doing this, the occiput fell precisely 
against her arm, as it supported the head; there was a difficulty in the 
child's laying hold of the nipple, and she attempted to force it into the 
mouth by pressing this firmly up against the breast. This plainly increased 
the difficulty, for the pressure of the child up to the breast, by the arm 
supporting its head, and acting upon the occiput behind, evidently produced 
a deeper displacement of this bone, and so every effort on the part of the 
mother, while she thus held the child, only aggravated the trouble. See- 
ing that there was no chance for it to suck in this way, I requested the 
mother to take her arm from under its head, while I would support it in 
my hands. I now held its head between my hands, gently and firmly 
compressing the parietal protuberances for five or six minutes, but with no 
pressure on the occiput; and it sucked with the greatest ease; indeed, most 
ravenously. I then changed the pressure from the parietal to the occipital 
bone, and instantly the same difficulties occurred, as when the head was 
resting on the mother's arm ; and thus I occupied myself for nearly half an 
hour in alternately producing and relieving the symptoms of lock jaw; in 
the first instance by displacing the occiput, and in the next, by replacing it. 

" I did not intend giving the child any medicine, but Mrs. A. insisted on 
its having * a good big dose of calomel.' Knowing that she would not be 
satisfied if I did not prescribe something more than mere change of position 
for so grave a case, I poured out a few grains of prepared chalk, and re- 
quested her to give the calomel at night, and to be particular to keep it on 
one side or the other, all the time. The child had taken any quantity of 
chalk mixtures before, without producing the slightest good result: sol 



64 



Sims on Trismus Nascentium. 



[July 



concluded that I might venture on this as a placebo, without any danger of 
dividing the honors with change of position. 

" Next day, I visited my little patient, and Mrs. A. met me at the door, 
in perfect ecstasies with the results of the quasi dose of calomel — said she 
had never seen calomel exert such miraculous effects in so short a space of 
time; that the child had had two good bilious evacuations for the first time 
in its life ; that it sucked well, (I had directed the mother how to nurse it 
without pressing in the occiput,) and looked better than any one could 
have hoped. Its passages (as before remarked) had always been greenish 
mucus without fetor, but I now found them natural in appearance, and fetid 
enough. In three days, I discharged the case as cured, not having given 
any physic save the few grains of prepared chalk." 

I visited Dr. Vickers' patient with him, on the 13th April, eleven 
days after he first saw it. I found the child quite lively, and fattening 
very fast. It had a pale, ashy look; indeed, it was as pale as a mulatto, 
but is evidently free from any taint of that sort, for its parents are quite 
black. The occipital region was perfectly clear of hair. The occiput was 
not pushed under, as at first, but still its edges were within those of the 
parietal bones. It was movable by pressure. While examining this 
bone, it occurred to me to try the experiment of pushing it in on the brain; 
so I placed my two thumbs on the pars occipitalis, grasping the lateral and 
anterior parts of the skull with the hands, and thus, by the use of consi- 
derable force, I displaced it suddenly. What was my surprise to see, in 
an instant, the immediate reproduction of the involuntary gyrations of the 
right arm and leg, with a motionless state of the opposite side. This ex- 
periment was often .repeated, with precisely the same results. Each time, 
as the pressure was removed, the symptoms ceased, the bone resuming its 
position with the cessation of the pressure. By these experiments, I 
also had the satisfaction of fully verifying Dr. Vickers' observations on the 
trismal symptoms in connection with the displaced occiput. 

On inquiry, the mother informed me that the child had never been well 
since it was born; that it never had a natural or healthy-looking passage 
from the bowels, till Dr. Vickers was called to see it; that it did tolerably 
well till it was about a week old, when it became fretful, refused to suck, 
made " a curious noise in its throat" (stridulous inspiration) ; that some- 
times it would suck pretty well, and then, again, it could not ; that it had 
a perpetual bowel complaint, and for the last two or three months, had 
passed thousands of little, fine thready-looking worms. 

It may be thought that I am occupying too much time with a single 
case, but it is so important in its bearings on the etiology of the disease, 
that I must be pardoned for adding a few words more. 

It might be said, " If the occiput was so much displaced, and the child 
lived five months, how is it that they die very suddenly, and that often, 
when the occiput is so slightly displaced as to be scarcely discoverable?" 
Let us examine the facts of the case for an explanation. The child was 
kept all the time in a cradle, without a nurse. The cradle was too short 
to allow it to lie flat down, so it was kept in a semi-erect position, with its 
head supported by a large (not very soft) old pillow of chicken-feathers, 
all matted together — the cradle was too deep and narrow to allow it to turn 
on its side, even if it had been strong enough to do so — the unvarying »* dor- 
sal decubitus" kept the occiput displaced ; the semi-erect position threw the 
weight of the head on that point of the occiput between the occipilal pro- 
tuberance and the posterior fontanelle ; this necessarily tilted the meso- 
cephalon forwards against the cuneiform process of the occipital bone, and 



1848.] 



Sims on Trismus Nascentium. 



65 



pressure exerted on the pons* always produces chorea or paralysis, or both, 
in exact proportion to the amount and degree of pressure. The semi-erect 
position was altogether favourable to the prolongation of the disease (and 
of life), because, in a perfectly supine position, the weight of the head 
w r ould have rested lower down on the occiput, which would have displaced 
the bone, so as to press more on the medulla oblongata and the eighth pair 
of nerves, and thus the patient would, in all probability, have died, at a 
very early period, of asphyxia. Moreover, the semi-erect position favoured 
the return of the blood from the spinal veins into the general circulation, 
through their anastomoses with the cervical, azygos, dorsal, lumbar and 
sacral, thereby preventing the congestion and, perhaps, extravasation, which 
may result from the purely supine position. 

I will admit that the case above related has not a parallel, so far as I 
know, but it must not be supposed that chronic cases of trismus are uncom- 
mon. Most of our writers on the subject describe the two varieties of 
acute and chronic; thus Coley says (page 393) — "The chronic variety 
commences with dysentery, and is attended with a cold exsanguious state 
of the skin, whence it has been popularly denominated the ' white locked- 
jaw.' This form of the disease is tedious, and attended, as when dysen- 
tery is uncomplicated, with rapid emaciation, which renders ordinary treat- 
ment insufficient, and terminates in death." 

Case VI. — This case furnishes another example of the disease in a 
chronic form, and is related to me by Dr. G. A. Tompkins, of Pike Co., 
Ala., who writes thus: — 

" Some time ago, when casually passing a house in this neighbourhood, 
I was stopped, and asked my opinion in regard to the disease of a white 
child, as it was thought to be an uncommon case. My attention was called 
to an extensive phlegmonous erysipelatous inflammation of one arm, and 
the opposite thigh. On examining the child more closely, I discovered the 
muscles of the extremities to be rigid, and that there was considerable opis- 
thotonos, which circumstances, together with the unavoidable position on 
the back, induced me (from having a short time previously heard of your 
views of trismus nascentium), to make an examination of the occiput, which 
I discovered to be very much depressed, and considerably overlapped by 
the parietal bones. I was not called in to take charge of the case, but I 
directed them to lay it on its side, if possible. I afterwards learned that 
they tried to do so, but the tenderness of the hip prevented it from lying 
on one side, and that of the shoulder from the other; so it was allowed to 
continue on its back. It died five days afterwards. On making inquiries 
since, I learn that it was unable to suck when I saw it, that its dejections 
were of a dark-green dysenteric character, and, likewise, that it occasion- 
ally had spas?ns. It differed from the cases of trismus reported in your 
paper, (which I have since seen,) in the age of the patient, as this child 
was about Jive months old, though it was badly-grown, and very much 
emaciated. 

" November VSth, 1846." 

The six cases now related are all of one character — all plain and simple 
— all had the occiput shoved in to such an extent that it was easily detected 

* See an interesting paper on the " Source of Convulsions,'' by T. Wilkinson King, 
Esq. Med. Times, Oct. 1844. 



86 



Sims on Trismus Nascentium. 



[July 



by a very superficial examination, and all had been kept upon the back, 
and flatly so. 

I now pass on to a class of cases, where it is not so easy to detect the 
occipital displacement, and where, of course, there will be less of the " dor- 
sal decubitus;" but in which the true relative position of the bones may be 
readily detected, when the method of doing so is once understood. 

This is the class of cases which formed the basis of two excellent papers 
on this subject, by my friends, Dr. Baldwin,* of Montgomery, and Dr. Gail- 
lard,! of Charleston. Each advocates the old notion of the traumatic um- 
bilical origin of the disease; one contending that the " spinal hemorrhage" 
is a sequence of the spasms ; the other, that " it is not necessary to the 
disease." With the first, I shall agree that a child dying of trismus, really 
dies asphyxiated; and with the latter, that " the effusion of blood into the 
spinal canal," is not an essential and unvarying feature of the disease. — 
Their theoretical views I shall not touch ; but I may be pardoned for exa- 
mining a little into the facts adduced. Dr. Baldwin kindly invited me to 
see his case, both during its progress, and at the autopsy, and as it forms 
the basis of some practical remarks on the disease, I shall take the liberty 
of borrowing it from his published account. 

Case VII. — Dr. Baldwin says (loc. cit., p. 363) — "At midnight, the 
child became very fretful, and refused to nurse, and occasionally was no- 
ticed to 'jerk,' as if it had spasms, and continued in this situation through 
the night. Has passed the meconium, and its last operation was yellow. 

" 11 o'clock A. M. The mother is lying on a soft feather bed, and in 
every way comfortably situated. When questioned relative to what posi- 
tion she had kept the child in since its birth, she stated that it was her ha- 
bit to lie on her side, and that she kept the child on its side, facing her, 
changing its position as she changed her own from side to side, but never 
on its back. * * * * * * * 

" Among other prescriptions left for the child, I directed that it should 
not be allowed to lie on its back, and that its position should be changed 
often, from side to side, on a soft pillow. As regards the position of the 
bones of the head, they seemed to me to be about as regular and well-formed 
as in infants generally of its age. Dr. Sims thinks the lateral edges of the 
occipital bone are ' slightly' overlapped by the parietal. * * * * Dr. Bol- 
ing, after carefully examining the bones of the head, remarked, that if 
their position was remarkable for anything, it was for their very great re- 
gularity and uniformity." 

As I said at the commencement of this paper, I have found out that a 
child may have the occiput " slightly" displaced, without ever having been 
kept square upon its back, or even on a hard substance. And that this slight 
displacement is all sufficient to produce the disease in its most aggravated 
form. When my first paper was published, I was not aware of this fact, 
and it was fortunate for the discovery, that the first cases that occurred to 
me, had the occiput so plainly, and so much displaced, that it was almost 
impossible for the mind to view the disease in any other light than as aris- 
ing from the pressure exerted by the displaced occiput ; and particularly, 
where the disease existed in all its force, and where all the symptoms were 
relieved, just in proportion as that displacement was rectified. 

* Amer. Journ. Med. Sci., Oct. 1846, p. 353. 
j- South. Journ. Med. and Pharm., Sept. 1846. 



1848.] 



Sims on Trismus Nascentium. 



67 



Once thoroughly imbued with this idea, it was a very easy matter to de- 
tect "slight" variations, or degrees, of occipital displacement; and it was 
certainly not difficult to infer that a " slight" occipital displacement was 
sufficient to produce the disease ; particularly, when I found that every 
symptom yielded to its correction. 

No one would ever have supposed, a priori, that so " slight" a displace- 
ment as that noticed in Dr. Baldwin's case, could have produced the disease ; 
and if I had not since seen several similar cases remedied, I should not have 
felt warranted in claiming it as one arising from " occipital displacement." 

Dr. Baldwin does me ample justice in saying that "Dr. Sims thinks the 
lateral edges of the occipital bone are « slightly' overlapped by the parietal." 
He quotes me literally, and reports it honestly. 

As there was a difference of opinion between us in regard to the relative 
position of the occipital and parietal bones, and as other writers have re- 
ported cases in which " the occiput was not shoved under," I feel war- 
ranted in devoting a few words to the proper method of determining this 
point. 

In every case of labour, the occiput of the foetus is displaced inwards, 
with its lateral edges under the parietal bones. There is hardly an excep- 
tion to this rule. Moreau first observed it, and any man can easily satisfy 
himself of the fact. 

In two instances, I have seen the edge of the occiput along one arm of 
the lambdoidal suture, underneath the parietal, while the opposite one was 
above it. This is the only variation of the general rule that has fallen 
under my observation. That the occiput is displaced then, in every in- 
stance, at birth, is a truism, and needs no illustration ; but that it may re- 
main so for any length of time afterwards, requires some proof. 

Now, suppose I am called to a child, one, two, or even three or four 
weeks old, with symptoms of trismus. We will suppose, too, that it is a 
fine large child, hearty and plump in appearance, with the bones of the 
head well ossified. The mother says that she "always lays her babies on 
their sides." I wish to find out whether there is any occipital displace- 
ment. I run my hand around its head> applying the palm to the occiput, 
(as nine out of ten would do,) and feel no displacement. This is the cha- 
racter of one half the cases that occur, and this is the way in which they 
are' investigated. But now let me go to work to find out exactly the relative 
position of the bones. And here, let me say, that one of two things must 
invariably exist : either the occiput will be under the parietal, or the parietal 
will be under the occipital, according to the position in which the child 
has generally been retained. There is no such thing as the edges of these 
bones being in apposition or parallel with the commissures on the stretch. 
I have examined the heads of several hundred infants, since my mind has 
been turned to the investigation of this subject, and I have seen but very 
few during the first week, and none after the second, in which the edges 
of these bones were parallel, and the commissure on the stretch. This 
occurs only where the ossification is very deficient, is easily detected, and 
of course forms an exception to the general rule. Whoever, then, reports 
a case of trismus, saying that there was " little or no displacement of the 
occiput," or that " it was not more so than usual with children of that age," 
draws the conclusion from a superficial and careless examination, and the 
report of the principal fact is too indefinite to be of any value. He must 
examine it critically, and say positively, either that the edges of the occiput 
were under the parietal bones, or exterior to them. And now for the 



68 



Sims on Trismus Nascentium. 



[July 



method of finding this out. If it is not ascertained almost by the sight 
alone ; or if it is not immediately discovered by the usual careless way of 
running the broad surface of the hand around the head, (and this will not 
be done unless in cases where the child has been confined to an almost 
unvarying dorsal decubitus,) then I go to work in this way. — I press the 
forefinger pretty firmly against the occiput, about half an inch from the 
lambdoidal suture, and at a point about half way between the posterior 
fontanelle and the mastoid process — I now pass the finger slowly and cau- 
tiously across the suture ; at every step making firm pressure. When 
the finger arrives at the suture, or, more properly speaking, the commissure, 
if the occiput is under the parietal bone, it will be found to yield, and the 
finger coming in contact with the edge of the parietal, will have to be 
elevated a little so as to pass over on to its free border: but if the occiput 
is on the outside of the parietal, then the finger meets with no obstruction; 
on the contrary, it glides smoothly over, and falls on to the parietal. The 
proof of this will be found in a retrograde manoeuvre. Now place the 
finger in like manner on the other side of the lambdoidal suture, and pass 
it, as before directed, across the suture. If the occiput should be on the 
inside of the parietal, then will the finger pass over unobstructed, merely 
having to drop a little to come in contact with the occiput; but if it should 
be on the outside, then will the finger encounter its salient edge, and have 
to be elevated a little to get over it. By following this simple plan, there is 
no chance of making a mistake, or of even speaking indecisively on the 
subject. I wish to be fully understood in this matter, for upon the nice 
discrimination of "slight" displacements of this bone, will depend the lives 
of generations yet unborn. 

Now, this is the plan I pursued in the investigation of the case above 
referred to, and it was the only method by which the true relative position 
of the bones could possibly have been detected. 

But it may be said, " What if the bone was a little under the parietal, so 
little that two out of three could not detect it? Is it possible that it is sufficient 
to produce trismus ?" I answer emphatically, yes ! 

During parturition, the proper place for the occiput is underneath the 
parietal ; but in extra-uterine life, its proper and only safe position will be 
found to be in the outside of this bone. Usually the occiput gets right, i. e. 
exterior to the parietal (when a proper position is observed), in from twelve 
to forty-eight hours or more ; generally it takes about thirty-six hours. Once 
get the ccciput right, get it outside of the parietal, and it never goes back. 
You may then lay a child on its back with the most perfect impunity ; in- 
deed, I should as soon think of breaking in a stone arch with a blow from 
a reed, as to displace the occiput under these circumstances by merely a 
dorsal decubitus. 

But as these precepts are better enforced by practical illustrations, I shall 
proceed with my cases. 

Case VIII. — Mrs. Gregory's child, female, born on the 7th September, 
1846. I was called to see it on 1st Oct. at 8 P. M. It was then a few 
days over three weeks old. — Here I copy from my notes made during the 
visit. — The child has been perfectly hearty ever since its birth up to yester- 
day, when it seemed to be "stretchy and gaping," was restless, fretful, and 
made a distressing moaning noise ; slept some last night, but not much; was 
constantly "twisting and screwing," and writhing about mechanically as 
if in great distress; mouth generally open, sometimes smacking the lips, 



1848.] 



Sims on Trismus Nascentium. 



69 



and all the time lolling out the tongue. Has not sucked since it was taken 
yesterday.(thirty-four hours) ; tried twice, but did not succeed. As the jaw 
is " fallen," it is easy to put the nipple into the mouth, but from want of 
suction power, it cannot draw the breast at all; seems to mumble it. The 
breast being full, some little milk was discharged into its mouth, which was 
swallowed. It appears to be tired, worried; grunts and moans perpetually. 
Breathing on the panting order. I requested the mother to lay it in the 
cradle, (where she usually kept it ;) she did so, laying it rather on the back. 
This evidently aggravated all its symptoms. After watching its actions for 
eight or ten minutes, I had it taken up and applied to the breast again, but 
it could not suck. It champs the nipple a time or two, looks fatigued, rests, 
and lets go entirely. It gapes, pants, moans, grunts, writhes about, lolls out 
the tongue, and then pukes by a sort of regurgitating process ; but this 
affords not the slightest relief. I had it applied to the breast again, but not 
a drop of milk was drawn. Its bowels are somewhat disordered. 

When I entered the room, the mother had the child in her lap, lying on 
its back, the occiput supported by her arm, the head rather hanging over it; 
thus making the greater degree of pressure low down towards the foramen 
magnum. I -inquired if she had kept the child on its back or sides mostly. 
"Oh! Doctor," says she, "I always keep my babies on the side, — never 
lay them on the back." While these words were being uttered, she held 
the child as above described. I now requested her to put the child to bed, 
and show me how she laid it; she put it in the cradle, and laid it, not upon 
the back, true, nor upon the side, but diagonally between the two. 

It was a fine, large, plump-looking child ; had the roundest, smoothest, 
prettiest head I ever saw. I ran my hand around the head to discover 
the relative position of the occiput and parietals ; but I did not even dis- 
cover the lambdoidal suture, much less any irregularity in the bones. This 
would have satisfied almost any observer. He would have said, "Well, 
the mother says she has kept the child on its side, and I can find no dis- 
placement of the occiput ; therefore, this case is opposed to the theory of 
occipital displacement." This logic did not satisfy me, because I knew 
that the edges of the occiput must be either within those of the ossa pari- 
etalia, or exterior to them ; and I knew, moreover, that, if the latter was the 
case, the child's position had been managed correctly: but if the former, 
that it had never been lain on its side properly, at least for any length of 
time. 

By applying what I call the test method, (described on page 68,) I 
soon discovered that the edges of the parietals were exterior to those of the 
occipital bone ; that the latter was movable by pressure from behind ; and 
that the left edge of the occiput was a little more displaced than the oppo- 
site one, which was shown by the greater prominence of the edge of the 
left parietal. By pressing forcibly on the central part of the " pars occipi- 
talis," with both of my thumbs, it was easily depressed, and all the child's 
distresses and mechanical manoeuvres were instantly aggravated, producing, 
however, no convulsive movements ; but a spasmodic quivering of the left 
hand appeared, just as the pressure was removed from the occiput. 

Well, the mother had laid it in the cradle, upon what mothers usually 
term the side, i. e., neither on the back nor on the side, but with the face 
looking in the direction of a line drawn diagonally between "a perpen- 
dicular and horizontal." I now tried what I call laying a child on the side. 
I "batted" a pillow up with more feathers at one end than the other, thus 
making a soft " inclined plane." The child was laid lengthwise the pil- 



TO 



Sims on Trismus Nascentium. 



[July 



low, on its side properly, with its face looking directly to the horizon, so 
that the weight of the head would be sustained on the surface embraced 
between the parietal protuberance and the outer edge of the orbit. As 
soon as the child was placed in this position, the mother exclaims, " Why, 
doctor, I have, as I told you, always laid the child on its side, but nothing 
like so much so as that." 

In a very few minutes, perhaps not more than five, the child showed 
manifest symptoms of improvement. It soon got perfectly quiet ; the 
moaning, " screwing and twisting,''' all ceased ; the breathing became 
calm, regular, and free, without any panting ; and it slept easily and 
sweetly. After awhile it waked: would occasionally let the lower jaw 
" fall," protrude the tongue gently and smack the mouth, like it was tasting 
something good; would occasionally open its eyes and look around, but 
without any motion whatever; indeed, it was wholly relieved, and that in 
the short space of 30 minutes. I left it for the night at 9 o'clock, with the 
injunction to keep it on its side property, not having ordered any medicine. 
It took the breast at 11 o'clock, (after having lain on the side for two hours 
and a half,) and sucked well, drew it strongl}\ went to sleep immediately 
afterwards, and rested finely all night. 

On the next day, (Oct. 2d, 7 A. M.,) the child was well, but the occiput 
was not. yet exterior to the parietal bones ; persevere with position. 

7 P. M. — Occiput not quite right yet; child quiet all day; sucked well; 
no moanings, stretchings, gapings, or distress of any sort; bowels have not 
been disturbed since the change of position last night. 

Oct. 3d, 8 A. M. — The occiput is now right ; is plainly exterior to the 
parietals, but can only be detected by the peculiar method already de- 
scribed. I directed the mother to keep the child on its sides a day or two 
longer, and then to lay it in any position she pleased. 

Now, there are some, (particularly those who have preconceived opin- 
ions to uphold,) who may doubt that this was a case of trismus. What was 
it, then ? Heretofore we seem to have been carried away by a name, or by 
notions. For instance — one will say, " I saw a case very much like tris- 
mus, the other day, in a child a week old; it could not suck, but then its 
jaws were not locked, for I could force them open by putting my finger be- 
tween them." He, led off by a name, had fixed in his mind the locking 
of the jaws as the characteristic feature of the disease, when all the world 
knows that, in trismus nascentium, the jaw is just as apt to be " fallen" as 
" locked." Another will relate a case, occurring, perhaps, on the third day, 
giving every essential symptom of the disease, and then say, " but there 
were no tonic spasms ; nothing, in short, characteristic of tetanus." He, 
too, had assumed one of the unvarying features of traumatic tetanus as pa- 
thognomonic of this disease. 

Here let me say, that there is one symptom of trismus nascentium, which 
is uniform, makes its appearance early, and (in conjunction with others) is 
a certain diagnostic ; and that is, the difficulty of sucking. The child 
may have no tonic rigidity ; clonic spasms may be wanting; it may even 
swallow with some degree of freedom; its jaws may not be locked; it may 
possibly sleep well, (perhaps too well;) its bowels may be in proper condi- 
tion; but if it goes long without sucking, if it cannot draw the breast, and 
if this cannot be accounted for by some competent physical cause, such as 
hare-lip, cleft palate, sore mouth, &c, then, I say, it has trismus. Let it 
then be remembered, that this inability to exercise the suction power con- 
stitutes the chief and almost the only unvarying early symptom of the dis- 



1848.] 



Sims on Trismus Nasceniium. 



71 



ease. It is pathognomonic, because unvarying ; but it never exists alone; 
it is always attended by other symptoms, which ought to arouse suspicion 
at once; such as moaning, sleeplessness or drowsiness, stridulous breath- < 
ing, borborygmi, diarrhoea, dysentery, whining, fretting, writhing, &c, all 
evidently manifesting some general derangement of the whole machinery. 
So well understood is this amongst the negroes, who have lost children 
with this disease, that they recognize it at once ; they look for this diffi- 
culty of sucking with the greatest solicitude, and when it occurs, they give 
up the child as irretrievably lost. They, with their unfortunately practical 
experience, will recognize the disease long before a physician, who is un- 
accustomed to it, will begin to suspect its true character. Indeed, physi- 
cians generally do not recognize it till it has advanced to the last or fatal 
stage. I well remember treating a case (ten years ago), when I thought 
the child was labouring under colic; it did not occur to me that it could 
not suck; I only thought that it would not, because it was in too much 
pain. My eyes were not open to its real danger, till the supervention of 
spasms, which soon carried it off. 

It would be fortunate, then, if we had some unfailing sign of this dreaded 
malady, so that we might recognize it at once, and apply the appropriate 
treatment. The inability to suck, I have pointed out as that sign. 

I will now go on to the consideration of a class of cases, which I shall 
denominate trismoid, for the simple reason, that they are wanting in some 
particular points which serve to characterize pure trismus, and yet present 
a chain of phenomena belonging to this disease, evidently produced by the 
same mechanical agency, and relieved in the same speedy manner. More 
properly speaking, they constitute the initiatory stage of trismus, lasting, 
however, for a long time without developing it fully. 

Mrs. S 's child, male, aged three weeks, when about eight days old, 

was noticed to be colicky ; has been so ever since, with a constant gurgling of 
wind in the bowels; for two days past has not sucked so well nor so strong 
as usual ; has a snuffling and wheezing in the throat, like it had taken 
cold ; has not slept so well for a week past as it ought. It is a very stout 
child ; head large; bones well ossified; occiput apparently all right; but a 
proper examination shows it to be " slightly" overlapped by the parietal 
bones ; child lies in a crib on a nice soft bed. The mother says she lays it 
on the side. I requested her to show me how she laid it on the side. She 
seemed quite astonished at my insisting on such a simple matter, as if there 
could possibly arise a question on that point. However, she put it in the 
crib, and laid it (as all mothers do, w r ho say that they are in the habit of lay- 
ing their children on the side, i. e.) diagonally on the side. I now showed 
her how to lay it properly on its side ; no medicine was given. The child 
rested w r ell that night, better than it had for two weeks. The colic, gurgling 
of wind, wheezing, and "slight" difficulty of sucking all disappeared di- 
rectly, and in thirty-six hours the occiput was occupying its proper posi- 
tion — exterior to the parietals. The change in the relative position of the 
bones, could only be detected by the proper method of examining it. 

Mrs. A 's child, male, six weeks old, had diarrhoea and colic; rested 

badly at night, and fretted very much during the day; was rather a puny 
looking child; had never appeared to thrive ; occiput under the parietals. 
I had directed the mother how to lay the child, when it was but a few days 
old, but my advice had not been followed, and, therefore, the occiput could 
not get out of its prison bounds. I gave no medicine, but simply placed 



72 



Sims on Trismus Nascentium. 



[July 



the child properly on its side, enjoining the necessity of keeping it so till 
I should order otherwise. In less than twenty-four hours, it was wholly 
relieved, and in forty-eight hours, the occiput occupied its only safe posi- 
tion on the outside of the parietals. It had no return of the symptoms, and 
began to fatten from that time. 

Mr. N 's child, male, nearly four weeks old, appeared to be doing 

well for the first eight or nine days, except that it drew the breast feebly ; 
sucks well now, (March 13th, 1847.) It makes a constant moaning, dis- 
tressing noise, day and night, but only when it is lying down ; has occa- 
sionally a panting respiration ; opening the mouth and protruding the 
tongue, like it was trying to get a hair or some foreign substance out of the 
mouth ; twisting round the head and writhing about, as if in pain. All 
this was supposed to depend upon the colic, and the father thought that 
he had prima facie evidence of it, from the fact that he could temporarily 
suspend the symptoms by laying the child on its belly, across his lap ; but 
they invariably returned when he would lay it down. Slamming a door, 
opening a window shutter, or any sudden noise, (even when slight,) easily 
wakes it up in a fright. It has a bowel complaint, which has persisted 
despite of every remedy, having appeared with the other symptoms about 
the ninth day. The attending physician has been giving chalk mixtures, 
carminatives, &c, without the slightest good effect. It had no tonic rigidity ; 
no clonic spasms; no locking of the jaws; no stoppage of the suction power, 
and was not, therefore, a case of trismus ; but the age of the patient, and 
the symptoms, clearly indicated its trismoidal character. 

The bones of the head were remarkably well ossified. The child had 
never lain properly on its side, though it had never been kept flat on the 
back. Occiput " slightly" under the parietal bones, more so on the left 
than the right side, particularly down towards the mastoid fontanelle, disco- 
verable only by the correct method of examination. I gave no medicine, 
but placed the child properly on its side, with orders to persevere till it 
should be relieved. In less than a day, the diarrhoea and all its distresses 
disappeared ; and on the third day, the occiput was found to be exterior to 
the edges of the parietal bones, which, to the practised touch, could be 
easily discriminated. There was no return of any symptom of the disease 
afterwards. 

Mr. May's child, male, is now just nine days old, (Jan. 30th, 1847.) 
Has been perfectly well till last night. About midnight it was observed to 
groan, and make a very distressing noise, which has been kept up with 
little intermission during this whole day. Can suck, but seems to be rest- 
less and uneasy, constantly opening the mouth, and protruding the tongue. 
Has kept the eyes closed all day, even when not asleep; has borborygmi, 
with looseness of the bowels, and manifests, in its actions and general ap- 
pearance, so many of the symptoms of trismus, that the father felt satisfied 
that he would lose the child, as he had lost one before of this disease. The 
mother had it in her lap, lying on its back. The father said, that, having 
heard of the danger of a dorsal decubitus in producing this dreadful mala- 
dy, they had been particular to keep the child on its sides, for the express 
purpose of preventing the disease. It lay usually in a cradle, day and 
night, with a pillow cross-wise under its head, which thus formed a con- 
cavity fitting the head exactly, and thereby preventing a proper lateral de- 
cubitus. The head was large, round and smooth, well-ossified — fontanelles 
very small. Occipital region felt smooth and regular, but by the applica- 
tion of the method so often alluded to, it was easy to detect a slight inward 



1848.] 



Sims on Trismus Nascentium. 



73 



displacement of the edges of the occiput, thus proving that the child had 
never been laid, for any length of time, on its side, the word of the parents 
" to the contrary, notwithstanding." 

While examining the occiput, (the child being very quiet,) I pushed it in 
forcibly on the brain — the consequence was, that the displacement was now 
perceptible to the eye ; whereas, before it could only be recognized by the 
touch. This pressing-in of the bone caused increased uneasiness to the 
child, as manifested by borborygmi, discharge of feces, a writhing about, 
opening the mouth, protrusion of the tongue, and a general restlessness. 
Before this disturbance of the bone, the child was lying perfectly quiet, and 
had been so for some time. Of course, I do not call this a case of trismus, 
because there was no permanent loss of the suction power, or control of 
the jaws ; but it would, doubtless, have resulted in this, if nothing had 
been done. I gave no medicine, but instead of placing the pillow cross- 
ivise the cradle, I put it lengthwise; and showed the mother how to lay 
the child properly on the side. It was almost instantly relieved of all its 
little distresses, and never had the slightest symptom of a return of them. 
It slept sweetly all night, and next morning the occiput was exterior to the 
parietals. It was kept on the side for twenty-four hours longer, when the 
mother was allowed to lay it as she pleased. 

Mr. Brewer's child, male, (born 7th Sept., 1847,) has never appeared to 
be well ; cried and screamed all day, the day it was born. It is now be- 
tween three and four weeks old, and has never slept at all, unless when 
under the influence of an anodyne; " never slept a wink yesterday;" is 
all the time restless ; bowels in a very bad condition ; passages curdled ; 
has a dozen or more in the twenty-four hours ; has a sort of straining, or 
bearing down, often, when the bowels are not moved ; during these par- 
oxysms of straining, the child turns red all over, and looks like the blood 
would gush out of its face. On the 9th and 10th days, it was taken with 
spasms, which are described as being intermittent, or clonic, and seemed 
to draw his head backwards. A dose of calomel had been given on the 
morning of the 9th, just before the access of the spasms. He has sucked 
well, vigorously all the time — has never vomited more than two or three 
times. Has been dosed constantly with paregoric and Dewees' carmina- 
tive. Has taken, frequently, as much as twenty drops of paregoric, and 
twenty-five drops of the carminative, before quiet and sleep could be in- 
duced. 

It is natural for infants to sleep almost all the time, unless when nursing; 
and when we find a child exhibiting the singular phenomenon of perpetual 
wakefulness, we must feel anxious to " know the why and the wherefore." 
Physicians had seen this child, and examined its head, to ascertain if there 
was any irregularity in the bones to account for all this derangement ; but 
none was found. The child had been laid (as the parents say) on the side ; 
but it had been kept in a cradle, and I affirm that it is impossible to lay a 
child properly on its side in a cradle as usually fixed. 

Well, it was a fine, large child; cranial bones well ossified ; head round, 
smooth, even and regular to the feel. No one could detect any irregulari- 
ty in the relative position of the occipital and parietal bones by sight, nor 
even by touch, unless examined in the peculiar manner so often alluded to; 
and then there was no difficulty in ascertaining that the edges of the oc- 
ciput were underneath those of the parietals. I placed the child properly 
on the side, on a pillow, lengthwise (in the cradle). At first, it was very 
restless, and I persevered for thirty minutes before the least effect was pro- 



74 



Sims on Trismus Nascentium. 



[July 



duced ; after this, it went to sleep, slept well, and was quiet all day, for the 
first time in its life, without the administration of an anodyne. The bowels 
got in a good condition immediately after a proper position was instituted, 
so as to take the pressure from the occiput, and allow it to gain its normal 
relations. I saw the child six days afterwards, and found the occiput exte- 
rior, requiring, however, a nice examination to detect it. 

I could relate several cases more of this trismoid affection, but there is 
such a sameness in them, that these five will suffice. They are important, 
inasmuch as they are of not unfrequent occurrence, and constitute a class 
of infantile diseases that has never been understood. They are important, 
too, because, unless controlled, they progress slowly, but very surely, to a 
fatal termination ; either by general convulsions, or by marasmus and ex- 
haustion, the consequence of a prolonged diarrhoea. 

Who, in a practice of ten years, cannot call to mind some similar case, 
where the little victim was dosed with carminatives, or purgatives, or as- 
tringents, or baths, or all? where, perhaps, the symptoms persisted for an 
indefinite period, despite of everything that could be done ! or, where, may 
be, they were relieved speedily; and as the physician supposed, at the 
time, by the potency of his prescriptions ; when, in reality, it resulted from 
an accidental proper position after a change of diaper, or removal from a 
bath. Does not this accidental way of curing the disease fully explain the 
secret of Dr. Eberle's* success in the treatment of trismus, by the appli- 
cation of blisters to the neck (and to the umbilicus)? What man in his 
senses would lay a child on its back when there was a blister on the nape 
of the neck ? Does it not also explain the secret of cures effected in a 
case related by Professor Stone, of New Orleans, before the Physico-Medi- 
cal Society, in which the mother smeared the child all over with sweet oil, 
and it was made whole ? Was it the oil that effected the cure, or was it 
an accidental proper position afterwards ? 

A gentleman of my acquaintance, who has lost nearly fifty negro chil- 
dren of this disease, informs me that he once relieved one by administering 
a whisky-bath, but that he has bathed twenty in whisky since, without pro- 
ducing the least effect. W T as it, then, the whisky that cured the child? 
Or, did it get w T ell by a mere accident? 

One of my own children, now eight years old, had trismus on the ninth 
day. The case was fully developed. It was nursed faithfully — too well — 
was held in the arms all the time. At last, after a night of the most pain- 
ful anxiety, the mother, exhausted and dispirited, laid the child in bed, giv- 
ing up all hope of its recovery. To the astonishment of all, my child was 
in a few hours well. The sudden change was always a mystery to me, 
till the discovery was made that now engages our attention. 

But I leave these circumstantial cases for the present, and pass on with 
such as are not susceptible of doubt. This brings me to the consideration 
of a class of cases, in which position alone cannot rectify the displaced oc- 
ciput. This peculiarity, so far as I have observed it, depends upon one of 
two conditions : either the bones are too well ossified, and, consequently, 
too much impacted against each other to allow of any motion whatever ; 
or else the occiput may be so mats hap ed as to present a physical barrier to 
a proper rectification of it. And here a surgical operation becomes indis- 
pensable to the safety of the child. 

I shall introduce this subject by relating a case that occurred to Professor 
Harrison, of New Orleans. 



* Western Lan.et, Oct. 1845. 



1848.] 



Sims on Trismus Nascentium. 



75 



Case IX. — Professor Harrison, in a critique on my first paper, [New 
Orleans Med. and Surg. Journal, July, 1846, p. 90,) says — " The writer 
of this notice was called, Feb. 14th, 1845, to see the child of a gentleman 
residing in New Orleans. It was the third day from the birth of the child, 
and the father informed us that the labour had been a protracted one — that 
the child, soon after birth, had been seized with convulsions, which had 
been continued, at intervals of from one to three hours, up to the moment 
of our visit. We were also told that the physician who had been in at- 
tendance had retired, giving up the case as hopeless. The child's bowels 
had been evacuated, and it was a well-formed, stout infant. 

44 Upon examination, we found the patient extremely drowsy, as if suf- 
fering from cerebral congestion: we found, also, the pupils considerably 
dilated. There were no tonic spasms. During the examination, a convul- 
sion came on, which lasted about ten minutes, and then ceased, leaving the 
child tranquil, as before. The examination being resumed, we discovered 
the injury spoken of by our author — namely, a depression of the occipital 
bone under the parietals. The depression was very great, but considera- 
bly greater on the right than on the left side. 

44 As warm baths, and, in short, everything usually resorted to in such 
cases, had been employed in vain, it struck us that the child might be re- 
lieved by an operation. We called on Dr. Hunt, and requested him to see 
the case with us, telling him the particulars, and mentioning that, if he 
agreed with us, we would, with the consent of the parents, perform the 
operation. Dr. Hunt coincided with us in the propriety of the operation, 
and having obtained the parent's consent, the operation was performed. It 
consisted in cutting down on the right side, where the greatest depression 
was — cutting through the soft union between the occipital and parietal 
bones with a common scalpel — and reducing the dislocation as much as 
possible, by means of the director found in the common pocket-case — using 
it as a lever. 

44 Immediately after the operation, the child was seized with a violent 
convulsion; but it was the last one it ever had. Up to the present time, 
(June 1st, 1846,) it has enjoyed uninterrupted good health, and is as fine 
and stout a child of its age as any in the city. 

44 In justice to Dr. Sims, we must also mention, that, in consequence of 
the wound on the right side, the child was kept reclining on its left. Ac- 
cording to his views, this position may have had great influence in the 
happy issue of the case." 

The following extract is from Professor Harrison's reply (dated New 
Orleans, Jan. 26th, 1847), to some inquiries touching this interesting case. 

44 The mother's recollection appears to be very distinct and positive. 
The information I gain from her is as follows : — The child was attacked 
with convulsions about twenty-four hours after birth. They were frequent 
and violent. The operation was performed fifty-five hours after birth, or 
thereabouts. The child had not taken the breast before the convulsions 
came on. It was tried once or twice, and on the first trial, the first con- 
vulsion occurred. It took the breast on the second day after the operation. 
I could not obtain the precise time, but the mother thinks the day after the 
operation, it swallowed a little milk and water. [The italics are my own.] 

44 The mother corrects an error into which I had fallen with regard to 
the convulsions after the operation. Instead of having but one. as I as- 
serted in the Journal, she had them frequently for six hours, when they 
ceased entirely." 



76 



Sims on Trismus Nascentium. 



[July 



The inability to suck (which continued from birth till the second day- 
after the operation), was alone sufficient to establish this as a case of tris- 
mus ; but the convulsions appeared to mask almost every other feature. 
The point of most interest to me, however, is the operation, which Profes- 
sor Harrison so successfully executed. The operation was greatly assisted 
by a proper position ; for the convulsions did not cease till six hours after- 
wards; showing, that while the right side of the occipital bone had been 
elevated by the operation, the left had to get out by a slower, but seldom 
less certain, process, viz., that of position. Although a proper position will 
rectify the occipital displacement in the great majority of cases, still, my 
facts go to establish the justness, and, occasionally, absolute necessity, for 
resorting to the operation of Professor Harrison. 

He deserves, and, I have no doubt, will receive, the credit of being the 
first to propose and to perform an operation for the cure of trismus nas- 
centium. 

It will be fortunate if we should be able to point out the peculiarities of 
such cases as will require surgical interference, so that we may proceed at 
once, without jeopardizing the life of the child by waiting the results of 
position. 

With a view to this, I will relate 

Case X. — Dr. M 's child, male, born on 10th Nov., 1846, after a 

labour of thirty-six hours. The doctor sent for me on the eleventh day, 
supposing that the child was suffering from the colic. For the first twenty- 
four hours, it had some difficulty about urinating. It had, for several days, 
a sort of belching, windy state of the bowels, attended by a writhing and 
constant moaning as if it had the colic — dejections small, frequent and 
curdled. Four days ago they were very copious, and of a yellowish- 
green ; but for the last thirty-six hours it has been costive. It does not 
sleep at all — grunts and moans all the time, and occasionally screams out 
suddenly. Feet and hands have generally been cold. Had slight clonic 
spasms last night, for the first time. Has not sucked at all since yesterday. 
Has never sucked very heartily. Could not swallow last night. Would 
spit out every now and then, as it were, mechanically. The doctor did 
not think it had trismus — thought there was no occipital displacement. — 
Said the child had been kept carefully on its side to prevent the disease. 
Although the " gurgling in the bowels," and general colicky symptoms 
were conspicuous, still, it was no difficult matter to see at once the true cha- 
racter of the disease. An examination of the occiput soon showed that its 
edges were within those of the parietal bones. I now wanted to be satisfied 
about its being " kept carefully on the side; to prevent the disease ;" so I 
requested Mrs. M. to let me see her place it on its side. She laid it in the 
cradle, not on the back, nor on the side, (as I have before remarked,) but 
with its face turned in a direction diagonally between these two positions. 
Now, this is the position that every child is obliged to occupy that lies in 
a cradle— and why so? To prevent the child from falling out during the 
rocking process, the cradle is, of necessity, never more than half full of 
bedding. It has then to lie in a hollow, apparently scooped out just to fit 
the occupant. And if a child were laid properly on its side in such a mur- 
derous contrivance, it would be smothered directly ; because its breathing 
would be obstructed by the pillow, or that portion of its bedding rising up 
by the sides of the cradle ; so that it is obliged to lie, either on the back, 
or in this semi-lateral position, which as effectually prevents the occiput 



1848.] 



Sims on Trismus Nascentium. 



11 



(in well-ossified heads) from getting exterior to the parietals, as does pres- 
sure from the dorsal decubitus. True, it does not push the occiput any 
further under the parietals, for the weight of the head falls exactly on that 
part of the parietal embraced between its protuberance and the lambdoidal 
suture, which locks, as it were, the occiput up inside ; whereas, when the 
weight of the head falls on that part between the protuberance and the 
edge of the orbit, (as in a proper lateral decubitus,) the lambdoidal edge, 
instead of being shoved on to the occiput, opens, and allows this bone to 
get on the outside of it. Once outside, the lateral position continued for a 
short time, causes a slight approximation of the lambdoidal edges of the 
parietal bones, which serve as points of support to the edges of the extruded 
occiput, forever preventing its return, and affording perfect immunity from 
danger during the most prolonged dorsal decubitus. But to return to the 
case. 

It was a fine large child — head remarkably well ossified — anterior fon- 
tanelle not more than half an inch across. The occiput was very peculiar. 
From the protuberance up to the apex, the "pars occipitalis" appeared to 
be too much curved imvards ; which evidently prevented it from getting 
exterior to the parietal bones. It seemed to be but slightly movable, and 
quite impacted, particularly towards the mastoid fontanelles. I had the 
child placed properly on its side. 

For one hour afterwards, it seemed to complain a good deal, moaning 
and writhing about almost constantly; then it got apparently more easy, 
moaning and grunting only occasionally. It then fell asleep for an hour, 
but groaned every now and then. The mother said it had not rested so 
well, nor so long, in twenty-four hours. This induced me to hope that a 
perseverance with the lateral decubitus might possibly do some good; yet 
I explained to the Doctor that an operation would probably be necessary, 
before the bones could assume their normal relations; but, that I did not 
feel warranted in resorting to it, till we had tried a proper position for a 
reasonable length of time. 

I left at two o'clock P.M., and at three, the child took spasms, and had 
them off and on for about three hours, when the Doctor applied cold water 
to the head, which appeared to modify in some degree the convulsive efforts, 
without controlling them. About ten o'clock, it got a great deal worse — 
tonic rigidity was extreme; clonic spasms more violent; and it died at 1 
A. M., exhausted and asphyxiated. 

The following notes were made at the visit next morning: 

The navel had healed beautifully. The ossification of the cranial bones 
was more perfect than usual; the anterior fontanelle very small indeed. 

The edges of the occiput are under the parietal bones. Generally, after 
death, the foetal cranial bones are easily movable, the occiput being made 
to slide under, or over the edges of the parietals at will, by proper pressure 
with the fingers; but, in this case, there seems to be a perfect impaction; 
for the edges of the bones along the mastoid ends of the lambdoid suture 
can be made to slide (by considerable force), alternately over and under 
each other; while along that part of the suture from the curve of the occi- 
put up to the posterior fontanelle, this bone remains obstinately under the 
parietals, despite of the strongest efforts to force it out. As before remarked, 
the occiput appeared to be too much curved inwards, which anatomical 
peculiarity accounts for the utter impossibility of rectifying its relative 
position. 

No. XXXI.— July, 1848. 6 



78 Emerson on the Proportions of the Sexes at Birth. [July 



I felt extremely anxious to ascertain whether this anomalous condition 
would present an insurmountable barrier to the rectification of the occiput, 
even hy operation. 

After long persuasion, Mrs. M. consented to let me make the attempt, 
provided it could be done without cutting. (For this proviso, I now feel 
thankful, as will be exhibited by a class of cases yet to be related.) 

I ran a short, stout, narrow-bladed knife between the bones on the left 
side, about an inch from the posterior fontanelle, its point resting on the 
edge of the occiput; and making a lever of it, the edge of the parietal act- 
ing as the fulcrum, the occiput was prized out from under the parietal, and 
made gently to overlap it; but it instantly returned to its old position, by 
withdrawing the lever. I again prized it out, but it slipped back in like 
manner. I then prized it out, and had forcible pressure made on the edge 
of the parietal, so as to prevent its return, till I could in the same way prize 
it out along the right side ; after which, the bone would remain in its 
proper position while the body was laid on the side; but would immediately 
return to its old place by laying it on the back. Thus proving, pretty 
clearly, that the child's life might have been saved, by a timely surgical 
operation. 

It is very desirable to determine what cases will require surgical inter- 
ference ; and particularly, to determine how long we may safely wait, before 
we ought to resort to it. Life w T ili occasionally depend upon the decision. 

I would lay it down as a general rule, that, if the bones of the head were 
remarkably well ossified, if the occiput seemed to be immovably impacted 
under, and between the edges of the parietal bones, and then, if a proper 
lateral decubitus, persevered in for three or four hours, did not relieve or 
greatly ameliorate the prominent symptoms, I would feel no hesitation in 
resorting to Professor Harrison's operation (or a modification of it), for ele- 
vating the depressed bone. 

We shall continue the consideration of this subject in a future number of 
this Journal. 



Art. V. — On the Causes operative in determining the Proportions of the 
Sexes at Birth. By Gotjverneur Emerson, M. D. 

In an article published in the American Journal of the Medical Sciences, 
(Nov., 1831,) we gave some results of statistical investigations into the births 
which had taken place in Philadelphia during the ten years embraced be- 
tween 1S21 and 1830. In viewing our tabular statements at that time, we 
were struck by the variations observed from year to year, not only in the 
totals, but in the proportions of the sexes. We entered into some investi- 
gations with the view of ascertaining whether influences might be detected 
in our locality affecting conceptions. This had been recently done in re- 
gard to Paris, by M. Villerme, and the results we arrived at were in singu- 
lar accordance with his, showing that the population of Philadelphia was 
subjected to agencies tending to operate unfavorably upon its increase from 



1848.] Emerson on the Proportions of the Sexes at Birth. 79 

reproduction. We regarded these as chiefly dependent upon the preva- 
lence of extreme heat, in summer, and the insalubrity of the first months 
of autumn. 

Whilst recently engaged in making out another series of tables showing 
the vital statistics of Philadelphia, for the decennial period embracing the 
years between 1830 and 1840, we had our attention drawn to a new fact 
connected with the mystery of reproduction.* 

In a table exhibiting the births during the ten years, one of the columns 
shows the excess of males over the females for each year. In passing the 
eye down this column, we were surprised to find the amount for 1833, re- 
duced to only 38, whereas, in the preceding year, it had been 415, and. 
generally, the preponderance of male over female births amounted to seve- 
ral hundreds per annum, being 6.29 per cent, for the whole decennial pe- 
riod. The total of births during the year 1833, was greater than that of 
the preceding year. Supposing that some error might exist in the calcula- 
tions for this year, we consulted the original records at the Health Office, 
and satisfied ourselves that the computations had been correctly made. 

In estimating the births for the months of April and May, 1833, we found 
that the males amounted to 532, and the females to 590, showing a female 
excess of 58, or about 10 per cent. Now these months include a period 
nine months after the time when the cholera prevailed, namely, August 
and September, 1832. It must be borne in mind that the ordinary average 
excess of male births, ascertained by former calculations, amounts to about 
7 per cent., so that the diminution of male conceptions during the cholera, 
was at the rate of more than 17 per cent. 

The effects of this epidemic upon the animal economy were not limited 
to those wrought through the disease alone; but included many strong 
moral and depressing influences exerted during most of the year, embracing 
the painful periods of anticipation and presence of the epidemic, with the 
secondary effects of the meagre diet generally adopted. 

The amount of conceptions during six months subsequent to the com- 
mencement of the cholera, exhibit a preponderance of females. 



Males. Females. 

Thus, the conceptions in August 1832, as shown by 



the births in 


April 1833, were 






272 


2S6 


The conception 


s in September 1832, by the births 


of May 1833, 


were 2G0 


304 


U it 


October 1832, 




June 1833, 


" 285 


2S3 


U (( 


November 1232, 


u 


July 1833, 


" 304 


296 




December 1832, 


u 


Aug. 1833, 


" 361 


330 




January 1S33, 


u 


Sept. 1833, 


" 344 


352 










1826 


1851 



* We should, perhaps, limit this remark to reproduction so far as the human species is 
concerned, for we are aware that experimental observations have shown that with 
sheep and some other inferior animals, certain measures pursued in coupling have ap- 
peared to exert an influence in determining the sexes. 



80 Emerson on the Proportions of the Sexes at Birth, [July 

It is proper to state that a slight visitation of epidemic cholera occurred 
in 1834, chiefly in the month of October, and that the returns of births 
which took place in June 1835, show a considerable falling off in the male 
births, which, instead of 7, amounted to only about 4 per cent. To all who 
have a distinct recollection of the two occurrences, it must be well known, 
that the solicitude and other depressing agencies operated in a trifling de- 
gree, compared with what they did in the first visitation.* 

In looking abroad to see whether any corroboration of the casual observa- 
tion made in Philadelphia was furnished by other places where cholera had 
prevailed, in the absence of the necessary data in our own country, we ap- 
pealed to the ample and accurate records of Paris, where, as is well known, 
the malignant cholera committed great ravages in 1832. Here we found, 
in a mass of no less than 33,367 births, a similar reduction in the proportion 
of the males, discovered in the Philadelphia reports. In addition to the 
confirmation of the singular fact thus furnished, the distinction made in 
Paris between the legitimate and illegitimate births, furnishes other evi- 
dence of a highly interesting nature, as will be perceived from the following 
statements. 

* The births in Philadelphia, for each of the 21 years in which a registration has been 
kept, with the proportions of the sexes, and excess of males, are as follows : 





Males. 


Females. 


Totals. 


Excess of n 


1820(a) 


1709 


1501 


3210 


208 


1821 


2630 


2417 


5047 


213 


1822 


3021 


2701 


5722 


320 


1823 


2977 


2836 


5813 


141 


1824 


3062 


2771 


5833 


291 


1825 


3444 


3181 


6626 


262 


1826 


3526 


3219 


6745 


307 


1827 


3581 


3452 


7033 


129 


1828 


3694 


3506 


7200 


188 


1829 


3638 


3357 


6995 


281 


1830 


3996 


3632 


7628 


364 


1831 


3787 


3555 


7342 


232 


1832 


3834 


3419 


7253 


415 


1833 


3840 


3802 


7642 


38 


1834 


3937 


3635 


7572 


302 


1835 


4041 


3815 


7856 


226 


1836 


3864 


3544 


7408 


320 


1837 


4235 


3953 


8188 


282 


1838 


3982 


3798 


7780 


184 


1839 


3769 


3493 


7262 


276 


1840 ' 


4223 


4010 


8233 


213 



(a) Only nine months of this year are included in the returns. 



1848.] Emerson on the Proportions of the Sexes at Birth. 81 



An estimate of the births in Paris for 1832, gives of 

Males. Females.' Total. 

Legitimates, - - 11,288 10,557 21,845 

Illegitimates, - - 5,032 4,853 9,885 



16,320 15,410 31,730 

15,410 



910 

Taking the returns for the whole year 1832, the legitimate males exceed 
the females about 6| per cent., whilst the male excess with the illegiti- 
mate was about 3£ per cent. 

When, however, the births are computed for December alone, that is to 
say, the ninth month after the most fatal ravages of the cholera, we find the 
excess of males entirely lost, and, instead, a considerable female prepon- 
derance. Thus : 





Males. 


Females. 


Total. 


The legitimates were, 


645 


679 


1324 


The illegitimates, - 


200 


199 


399 




845 


878 


1723 



The births in Paris during 1833 were as follows : 

Totals. 

Males legitimate, .... 11 852 ) Males. 

Do. illegitimate, .... 5,039 5 ' 
Females, legitimate, .... 11,434 ) F males 

Do. illegitimate, - - - 5,042 5 ' females. 



Excess of male births, - - - - - 415 

Of the grand total of births in Paris for 1833, the legitimate constitute 
23,286, of which there were 11,852 males, and 11,434 females, showing an 
excess of males of only 3£ per cent. The number of these born at home is 
22,861, viz., 11,642 males, 11,219 females ; showing an excess of males 
of about 3| per cent. 

The legitimate births in hospitals were 425, of which 209 were males, 
and 215 females, giving a small female excess of the legitimate births in 
hospitals. 

Now the portion of the population upon which the cholera of 1832 
bore hardest, was unquestionably that made up of the lower classes — the 
same which furnishes most of the illegitimate births, and in which, imme- 
diately after the cholera, we find the usual male preponderance annihilated, 
and a small excess of female births. 

In France, and elsewhere in Europe, it has been ascertained that the 
excess of male births is always less among the natural-born than with the 
legitimate. The results of estimates based upon a long series of annual 
observations in Paris, show that with the children born out of wedlock, the 



82 



Emerson on the Proportions of the Sexes at Birth. 



[July 



proportion of males to females is as 23 to 22, an excess of males of only 
about 4 per cent. Among the legitimate births, there are 16 males to 15 
females, or a male excess of about 6 per cent. 

When we consider the Paris births in 1833, with regard to the particular 
arrondissements, as indicating the parts inhabited by the rich, who were 
nearly exempt from cholera, and the poor who perished by thousands, we 
find the following results. 

In the 1st, 2d, 3d and 4th arrondissements, comprising the most popu- t 
lous and wealthy portion of the city, the total number of births was 6,664, 
of which 3,458 were males, and 3,206 females, being an excess in the 
males of nearly 7i per cent. 

The legitimate births at home, representing that portion of the popula- 
tion best provided for, were 5,126, viz., 2,666 males, and 2,460 females, 
showing a male excess of about 7f per cent. 

The illegitimate births at home amounted to 1511, viz., 779 males, and 
732 females, showing a male excess of 6 per cent. 

The births in the hospitals were so few as to make no sensible change 
in the results given. 

Let us now go to those parts of Paris where the cholera prevailed With 
such fatal fury, that, between the 26th of March and 18th of April, 1832, it 
swept off no less than 10,476 victims, the number of persons attacked being 
estimated at 30,000, not including the milder cases. 

These were the ill-ventilated districts embraced in the 8th, 9th, 10th and 
12th arrondissements, where the poor and necessitous most abound. 

The total of legitimate births at home was 6155, viz., 3137 males, and 
3028 females, a male excess of about 3| per cent. 

The legitimate births in hospitals were 301, viz., 179 males, and 188 
females, a female excess of about 5 per cent. 

The whole number of the illegitimate was 5617, viz., 2801 males, 
and 2816 females, showing a female excess of 15. Of these, 

The illegitimate births at home were 1622, viz., 815 males, and 807 
females, being a male excess of less than 1 per cent. 

The illegitimate births at the hospitals were 3995, viz., 1986 males, and 
2009 females, showing a female excess of 23. 

The total amount of legitimate and illegitimate births in the 8th, 9th, 10th 
and 12th arrondissements was 12,139, of which the males were 6117, and 
the females 6022, showing a male excess of only about 1| per cent. 

But it was in the 12th arrondissement that the greatest ravages of cholera 
were felt ; and the births in this constitute about half of those reported for 
the 8th, 9th, 10th and 12th arrondissements, namely, 6134, of which 3046 
were males, and 3088 females. 

Among the legitimates born at home, in this arrondissement, amounting 
to 1599, the males were 793, the females 806. The illegitimate births in 



1848.] Emerson on the Proportions of the Sexes at Birth. 83 



hospitals were 3779, viz., 1860 males, and 1919 females, a female excess 
of 59. 

Thus we find that, in the portions of Paris exempt from cholera in 1832, 
the births in 1833 show the unusually large excess of males of 7| to 
7| per cent. Even among the illegitimate births, the male excess was 
swelled to 6 per cent. But in those parts of Pff is which bore the brunt of 
the cholera, the male excess with the legitimate was reduced to 3| per cent., 
whilst, with the illegitimate, the female births actually preponderated.* 

The reports we possess only show the Paris births in each arrondisse- 
ment for the entire year, the monthly statements including the whole of 
the arrondissements. We are thus prevented from exhibiting the effects of 
the influences under investigation, as they operated in particular months 
in the separate arrondissements. This last, could it have been effected, 
would have been highly interesting. 

An attentive inspection of the very extensive reports made in several of 
the most enlightened countries of Europe, has proved to us most conclu- 
sively, that every influence operating in a community to maintain a high 
state of physical health and energy, leads to an increase in the proportion 
of male births; whilst, on the contrary, every agency, whether moral or 
physical, the effect of which may be to reduce the forces of organic life, 
will diminish such preponderance. In many parts of Europe, where the 
general population is over-worked and under-fed, the excess of male births 
is very small. Throughout Prussia and France, the excess of male legiti- 
mate births is usually under 6 per cent., and in England about 5 per cent, 
for the kingdom at large. In Philadelphia, where the condition of the 
general population is so favourable, the male births generally exceed the 
female about 7 per cent., whilst, in the rural districts of the United States, 
and especially in those most newly settled, the predominance of male chil- 
dren is much greater.! 

M. Quetelet, of Brussels, who has devoted much attention to subjects 
connected with the movements of population, in the course of one of his 
late most elaborate expositions, makes the following observation : "II est 

* Viewed in point of numbers, the Paris births in 1832 exhibit a considerable dimi- 
nution, amounting to about 5 per cent, less than the number reported in 1833. In the 
monthly returns, the falling off first manifests itself in August, 1832, and continues to 
February, 1833, from which it would seem that influences unfavourable to reproduction 
set in about the month of December, 1831, and continued till May, 1832, a space of 
about six months, including the period when the cholera prevailed. About nine months 
afterwards, in 1833, the births experienced a sudden increase from 2053 to25G9. This 
seems to show that, about the month of June, 1832, there was a subsidence of the influ- 
ences unfavourable to reproduction, which had been prevailing for some six months, 
followed by a restoration to extraordinary vigour, causing the male excess for the whole 
year to rise to 6, 7^, and even 7| per cent, according to the classes of Parisian 
population. 

| See American Journal of the Medical Sciences for Nov. 1827. 



84 Emerson on the Proportions of the Sexes at Birth. [July 



un fait remarquable, bien etabli aujourd'hui quoiqu'on n'en connaisse point 
encore les causes, c'est qu'il nait annueilement plus de gar^ons que de 
filles." 

We have not the presumption to attempt an explanation of the great 
primary law regulating the distribution of the sexes. But, at the same 
time, we believe that the flfcts just adduced, and others to which we shall 
refer, show causes — and some of these, more or less under human control — 
which operate in a very appreciable degree in determining the proportions 
of males and females in the human race. 

Disease, exhausting labour, scanty and meagre diet, impure air, intem- 
perance and other social evils, are depressing influences, the force of 
most of which bears much more heavily upon the inhabitants of cities than 
upon those of places less densely populated. 

An examination of the returns made for many years in France, Belgium 
and England, embracing millions of births, shows everywhere a greater ex- 
cess of males born in the rural population than in cities.* Here, then, are 
causes specified and always existing, which exert a decided influence in 
determining the proportions of the sexes born. When, however, we come 
to estimate the influence exerted upon large masses of people subjected to 
a pestilence singularly calculated to exhaust the physical energies, we view 
the subject as if placed in the focus of a magnifier. The depressing forces 
ordinarily existing we find capable of diminishing the males one or two per 
cent., whilst those exerted by a severe epidemic, like that experienced in 
Paris and Philadelphia, have brought down the ordinary male excess of 
about 6 or 7 per cent, to only 1 per cent. When the estimate is made so as 
to include the births in Philadelphia for the months of April and May, 1833, 
the conceptions of which took place in July and August, 1832, as well as 
the illegitimate births of Paris, we actually see the usual male excess an- 
nihilated and substituted by a female preponderance. 

To exhibit this subject in a still stronger light, let us take the sum of 
male excess, and instead of comparing it with the whole amount of male 
births, consider it by itself. Suppose the sum of 400 to represent the excess 
of males in 10,000 city births, and 600 the excess of males in the same 

* Observations collected in England of late years, and published in detail in the an- 
nual reports of the Registrar-General, show the preponderance of male births greatest in 
the northern and western divisions, including Wales; and it is precisely here where we 
should expect the powers of organic life manifested in a higher degree than in the 
southern divisions of the island, the seats of the metropolitan cities, where more 
ease, luxury, and effeminacy exist. In the American Journal of the Medical Sciences 
for January, 1844, p. 167, will be found an abstract from a report of the British 
Registrar-General for three years, during which there was a registration of the birth of 
760.983 boys, and 725,689 girls. The excess of males in all the districts is 4.86 percent., 
or in the proportion of 10,486 boys to 10,000 girls. In the northern and western divi- 
sions, the excess of boys amounts to 5.39 per cent , whilst in the southern and metropo- 
litan districts, the males at birth exceed the females but 4.35 percent. 



1848.] Emerson on the Proportions of the Sexes at Birth. 



85 



number of country births. The excess of males in the first-named dis- 
tricts would, therefore, be 33 per cent., or one-third less than that in the 
more rural districts, and this under circumstances ordinarily existing. 
But when the agencies exerted by the prevalence of a severe epidemic like 
the cholera, are brought to bear upon the population, the male excess sinks 
about 80 per cent, below the ordinary average. 

I believe it will be found that the extensive prevalence of every severe 
zimotic epidemic, or endemic disease; every occurrence, in fact, which ex- 
erts, either directly or indirectly, a decided depressing effect upon a com- 
munity, will be indicated in the record of births by a conspicuous reduction 
in the proportion of males. 

In our table showing the births in Philadelphia, there is a perceptible 
falling off in the preponderance of males, for the years 1837 and 1838. — 
This may, perhaps, be ascribed to the destruction of business and embar- 
rassment so generally experienced, and which commenced in 1836. The 
intense anxiety and great distress which prevailed and was kept up for 
some years after the financial crisis, must certainly have operated strongly 
upon a large commercial and manufacturing community, and, like all other 
depressing influences, tended, by indirect means, to diminish the energies 
of organic life. 

When a pestilence or violent epidemic passes through a community, it 
is generally the most feeble portion of the population that is swept off. The 
births soon after will exhibit an increase in the amount of males, because 
the parents will be those endowed with vital energies above the ordinary 
average, a proof of which is their exemption, or recovery, from disease. 

We think there is strong reason to believe, that the institution of poly- 
gamy grew out of a preponderance in the amount of female population, 
induced, perhaps, by a scanty supply of food, or from the use of a descrip- 
tion of diet not calculated to maintain a high condition of physical energy. 
Polygamy once established as a common usage, must tend to foster itself. 

In conclusion, it appears to us that the proportions of the sexes at birth 
are, to a considerable extent, subjected to circumstances more or less under 
human control, and that all measures tending to lessen disease, and promote 
the welfare and comfort of a population, while they serve immediately to 
increase the capacities for profitable labour, tend also to promote the multi* 
plication of the sex supplying the main physical power. 



88 



Atlee on Excision of the Cervix Uteri. 



Art. VI. — Excision of the Cervix Uteri for Carcinomatous Disease. — By 
Washington L. Atlee, M. D., Professor of Medical Chemistry in the 
Medical Department of Pennsylvania College, Philadelphia. 

Nov. 11, 1846, 1 was requested to visit Mrs. W., a lady 46 years of age, 
whose husband is still living. She has had nine living children, the 
youngest of whom is twelve years old, and one miscarriage — the first ges- 
tation — when about three months advanced. She has always been regular 
in her menstrual periods until September, 1845, after which menstruation 
ceased. She subsequently became annoyed by a troublesome leucorrhoea, 
which continued ail winter, occasionally being tinged with blood and mat- 
ter. Early in April, 1846, after having been much fatigued by a long 
walk, she was attacked with violent uterine pains and copious hemorrhage, 
which forced her to bed. She kept her bed about one month, during the 
time suffering greatly, and becoming very much reduced in flesh and 
strength. She could now discover, by introducing her finger, something 
like a tumour in the vagina. After this attack, she again recruited her 
general health, but in the latter part of June, was again prostrated by bleed- 
ing, at which time she passed from the vagina something Avhich, she said, 
resembled a portion of hollow skin about the length of the finger. The 
bleeding again ceased, but again recurred upon using injections prescribed 
by her physician. The case now assumed so serious an aspect that she 
came to Philadelphia for professional advice. 

I examined the patient for the first time, on the day above stated, by the 
toucher, and again, on the 15th of the same month, by the speculum. My 
opinion of the case was requested by the husband to be given in writing, in 
order that it might be submitted to her physicians at home, and is as follows: — 

"There is, in my opinion, a tumour, about two inches in diameter, of a 
flesh-colour, seated upon the posterior lip of the os uteri, and appears to have 
originated on its inferior border, and, developing itself towards the vagina, 
has extended the lip forwards and backwards, so as to invert the edges, 
without appreciably disturbing the integrity of the mucous tissue covering 
the anterior and posterior surfaces. The whole lower aspect of this tumour 
is ulcerated and covered with semi-botryoidal projections, which bleed upon 
handling. The tumour is seated upon a dense tissue, which dense tissue 
does not implicate the walls of the uterus, nor any point above the insertion 
of the upper part of the vagina. The uterus is retroverted, its body being 
easily felt, and capable of being well examined per rectum. The anterior 
lip of the os tincse, the vagina throughout its whole extent, the ovaries and 
broad ligaments, are free from disease. No glandular enlargements are 
discoverable in the pelvic cavity, in the groin, or elsewhere, and the ex- 
ternal genitals are healthy. There is no fetid discharge, no sharp lancinat- 
ing pains, no constitutional symptoms. On the contrary, Mrs. W. appears 
in excellent health, enjoys refreshing sleep and good appetite, and is free 
from much suffering. The pulse is soft, full, and open, ranging between 
80 and 90 when free from nervous excitement; its highest point, during 
the agitation antecedent to an instrumental examination, being only 104. 
The tongue is very slightly furred, and moist. The skin soft and moist — 
of good colour and temperature. Expression of countenance calm. 

"Viewing these symptoms collectively, I consider Mrs. W.'s case one 
purely of * carcinomatous ulcer,'' in which the hardening of the tissue is 
consecutive to the existence of the ulceration, and not a case of 'ulcerated 



1848.] 



Atlee on Excision of the Cervix Uteri. 



ST 



smrrhuSt or 1 ulcerated cancer,'' in which the hardening of the tissue pre- 
cedes the ulcer. This is a distinction of the utmost importance in deciding 
upon the propriety of any course of treatment, surgical or otherwise. [Vide 
Colombat on Diseases of Females, by Charles D. Meigs, M.D., 1845, p. 
327.] 

"Colombat says, 'a cutting instrument, under these circumstances, [i. e. 
in carcinomatous ulcers,^] can always cut beyond the limits of the disease. 
It is in this condition, more than any other, that the operation is called for, 
and promises the best chance of success; because the ulceration, which has 
been developed from without inwards, reposes upon a secondary induration 
of no great depth.' [p. 328.] 

"With this view of the nature of her disease, associated as it is with 
very favourable symptoms, appearing, indeed, as a local affection, I consider 
that an operation for the excision of the diseased structure perfectly justi- 
fiable, and affording, at this stage of its progress, the only chance of escape. 

"The operation is not likely to.be a very painful one. It has its dan- 
gers: bleeding from the wound, inflammation of the womb and its append- 
ages, inflammation of the peritoneum, nervous shock, and lastly, the repro- 
duction of the disease. The first four, although more or less dangerous, 
are within the power of remedial treatment, and every day's delay increases 
the hazard of all. 

"Should Mrs. W., after weighing carefully all the circumstances con- 
nected with her case, and with the operation, conclude to avail herself of 
this last resource, and desire me to undertake her case, I shall feel bound, 
under this opinion, by a conscientious regard to professional duty and to 
the welfare of the patient, to accede; and I sincerely hope, through the 
blessing of God, that the means may prove successful. 

" Washington L. Atlee, M. D. 

"Philadelphia, Nov. 17, 1846." 

December 1st. The patient was taken to New York with the hope of 
getting relief, without resorting to surgical interference, and, after spending 
eight or nine days there, returned completely disheartened and unnerved. 
She had had severe floodings, was now much worse, and was suffering 
considerable gastric distress, and agony through the pelvic region. 

11th. Dr. George McClellan examined the patient in consultation, and, 
agreeing in every particular with the above opinion, recommended the 
resort to the knife. 

The same evening the patient sent for me, stated that she had weighed 
the matter well, had decided upon the operation, and desired me to perform 
it, wishing, at the same time, not to be informed of it until the day fixed for 
it. Pulse 84. 

lbfh. The gastric disturbance was increased : there were considerable 
nausea and efforts to vomit. Pulse ranging from 88 to 104. 

16th. Dr. Samuel G. Morton was now associated in the consultation. 
He examined the patient, and coincided with us in opinion as to the cha- 
racter of the disease and the propriety of an operation. Agreeably to a 
mutual understanding, the general health was now placed under Dr. Mor- 
ton's special charge. 

21s/. The patient, having just passed through what was supposed to have 
been a menstrual period, and having recovered from the unpleasant symptoms 
mentioned, was considered in a proper condition for the operation, and ac- 
cordingly I announced to her my intention to operate this morning at eleven 



88 



Atlee on Excision of the Cervix Uteri. 



[July 



o'clock. She desired to have it postponed until to-morrow, but upon urg- 
ing it upon her, she readily yielded to our decision. 

The patient was placed upon a bed, her hips resting on its edge, in the 
position as for the operation of lithotomy, and well supported by assistants. 
Drs. George McClellan, Morton, Sharpless, Gilbert, Wiltbank, Grant, and 
Jno. McClellan, and several female friends, were present. With a for- 
ceps* constructed for the purpose, I seized the two opposite sides of the 
base of the tumour near the insertion of the vagina into the cervix uteri, 
and making gentle, but continued traction in the direction of the os exter- 
num, brought the posterior border of the tumour in sight. Its anterior 
part being still under the arch of the pubis, I gave the handle of the 
forceps into the hands of Dr. George McClellan, and applied the dou- 
ble-branched tenaculum high up on its anterior face, and brought that por- 
tion of the tumour down. Firmly maintaining the parts in that position, I 
now with my left index finger accomplished the delivery of the whole mass 
through the os externum. Dr. McC. taking charge of both traction-in- 
struments, I seized a probe-pointed bistoury, wrapped for about two-thirds 
its length, and cut above the insertion of the forceps, from before backwards 
towards the perineum, guiding the knife and guarding the parts with the 
left index finger, until I made the section complete, and severed, by a hori- 
zontal cut, the whole of the diseased mass.t The uterus at once receded. 
The parts were now carefully examined by the eye, and no diseased struc- 
ture appearing, a dossil of lint, charged with a powder composed of galls, 
tannin, and gum Arabic, was passed up to the cut surface of the uterus, a 
tampon of soft lint introduced, and the whole retained by a T bandage. 

The section of the cervix did not resemble the cutting of scirrhus, but 
more that of the ordinary tissue of the uterus, and the structure cut seemed 
to be perfectly healthy, both in feel and appearance. Very little hemor- 
rhage occurred — only one small artery spouted out, too insignificant to re- 
quire attention, or to excite alarm. .Nor was there any venous sinus 
opened. 

The operation lasted four and a half minutes, and was borne by the 
patient with very little manifestations of pain — the most suffering having 
been produced by dragging down the uterus. No gastric disturbance was 
excited by these efforts, and the amount of force required to accomplish this 
object was much less than had been anticipated. Forty drops of black 
drop had been administered two hours before the operation, and fifteen 
more just before the patient was brought into the operating room. The 

* These forceps are eight inches long, have scissor-handles, and a loose conical-pivot 
joint, similar to that in Siebold's obstetric forceps. The joint is placed at three and a 
half inches from the extremity of the handles, and from this point the blades are taper- 
ing and round, and curve gently upwards. The blades continue parallel to each other 
for five and a half inches, then curving outwardly, become flattened, and again meet in 
serratures at their extremities, which have a perpendicular width of half an inch. The 
forceps, when closed, therefore, forms, at its distal extremity, an oblate -spheroid, of one 
inch and a half conjugate diameter. 

By this arrangement I was capable of introducing the blades separately, and of fixing 
their teeth upon any part of the pedicle of the tumour, and then locking them, I could 
firmly secure the diseased mass in the ellipsoid. The instrument answered an admirable 
purpose. It is far superior for this operation to the forceps of Museaux, and much more 
simple than that recommended by Colombat. 

f The portion removed, it was thought, by those present, would weigh five or six 
ounces. A wax model was taken of it, and is in the museum of the Medical Depart- 
ment of Pennsylvania College. 



1848.] 



Atlee on Excision of the Cervix Uteri. 



89 



bowels had been opened in the morning, and the bladder emptied just be- 
fore the operation. 

The patient was now conveyed to her room on the same bed used for 
the operation. A tendency to syncope followed, and arrow-root and brandy 
were exhibited. The extremities and surface became cold, the pulse 
feeble, and there were efforts to vomit. Aqua ammonia, in ten drop doses, 
was given at intervals, with brandy, arrow-root, and toast water. They 
were again rejected after accumulating, accompanied with the discharge of 
considerable flatus from the stomach at the same time. In taking drink, 
every swallow was followed by borborygmus. 

These symptoms continued until about four o'clock, P. M. After this, 
there was very little gastric distress, the pulse began to be felt more sen- 
sibly, and the skin became warmer, the nose still remaining cold. The 
stimulants were now suspended, and cold water in teaspoonful doses sub- 
stituted. The most distressing symptom now complained of, and which 
annoyed the patient from the beginning, was a strong desire to urinate, 
and this was supposed to be owing either to the styptic or the tampon. 
7 P.M. Considered to be doing well. Had her lifted on to her own bed. 
Complains of cold feet. Relishes sago. 10 P. M. Has been quite calm 
for several hours, dozing some. Stomach quiet. Felt a little chilly, but 
asks occasionally to be fanned. Has some thirst, which is easily satis- 
fied. Nose now warm, and reaction appears perfectly established. Pulse 
has ranged between 90 and 98, and is acquiring more volume. There 
has been no hemorrhage — a little bloody serum stained the cloths. Turned 
the patient upon her right side. 

22rf. 3 Ji.M. Complains of pain in the lower part of the abdomen, 
which was, in a measure, relieved by removing, with the catheter, about 
four ounces of healthy-looking urine, the first passed since the operation. 
Hands a good deal warmer; pulse 10S, and fuller. Removed a portion of 
the lint from the vagina, which had dried, and adhered to the labia. Gave 
Ji spts. nitr. dulc, and, about an hour afterwards, ten drops of M'Munn's 
elixir of opium. 9<| A.M. Has had altogether a comfortable night — as 
much so as usual — troubled occasionally with colic pains, which she is 
liable to. Pulse 88. Two hours after this, I removed a portion of the 
tampon, and injected the vagina with warm flax-seed tea. Removed six 
ounces of healthy urine. 1 P. M. Enema of flaxseed tea, followed by a 
suppository of soap, and by saline injections. Complains of a tender and 
painful spot in the left groin, which has troubled her a long time before 
the operation. Applied a warm emollient cataplasm to the abdomen. 
10 P. M. Found the patient in much pain and agitation, in consequence 
of an accumulation of urine. Relieved by catheter. Afterwards, I with- 
drew the balance of the tampon, which had become very hard and conso- 
lidated, and washed out the vagina well with flaxseed tea. Administered 
fifteen drops of elixir of opium, which soon made her quiet and easy. 
Enema operated about 4 P. M. Pulse to-day, 88 — 98. Tongue rather 
more coated, but moist. Less thirst. 

23c?. 7 A.M. Has had a most delightful night ; sweet and refreshing 
sleep. Free from pain and soreness. Feels very comfortable, and says 
she is much better. Pulse 88. Used catheter. The serous discharge 
from the vagina more copious. Vaginal injections. Ordered thin chicken- 
broth. 4 P. M. Has had some chilliness ; is now feverish ; pulse 104 ; skin 
warm and dry. Lifted the patient to another bed. Had her clothing 
and bed changed. Says she is more comfortable. Used catheter ; also 



00 



Atlee on Excision of the Cervix Uteri. 



[July 



at 1 P. M. Urine containing a deposit of mucus. Ordered 5 grs. cryst. 
bicarb, pot. every two hours. Vaginal injections of a solution of the hy- 
pochlorite of lime. 12, M. During the evening, some tenderness over 
the hypogastrium, and left iliac region. Pulse 115. Catheterism. Much 
less mucus in the urine. Saline enema brought away feculent discharges, 
and the tenderness of the abdomen was somewhat relieved. 

24th. 5 A. M. Pulse 118. Skin warm and dry. Tongue covered with 
a dense white coat. Some thirst. Abdominal tenderness the same. Ca- 
theterism. Examined per vaginam — not much heat or tenderness of the 
parts. Continued vaginal injections. Gave two teaspoonfuls of calcined mag- 
nesia. 1P.M. Pulse has come down to 94. Magnesia operated twice, pro- 
ducing large, very feculent discharges; yellowish, and containing scybala. 
Catheterism. Has felt chilly about the thighs and arms, and complains of 
headache. 3 P. M. Considerable fever following the chill. Pulse 120, 
full and rather hard. Skin dry and warm. Complains of headache and 
burning heat. Venesection until skin was relaxed, and pulse softened, 
requiring about eight ounces of blood. Followed by fifteen drops of elixir 
of opium. Discharge from vagina less sanguineous. Catheterism. 7 P.M. 
Very comfortable since, excepting a transient neuralgic pain attacking the 
two elbows, and which was relieved by a rubefacient. Pulse 110, soft, full 
and open. Skin rather relaxed ; soft. Temples moist. 12 M. Rested 
well all evening: tenderness of abdomen much diminished. Catheterism 
and vaginal injections. 

2oth. 9 A. M. Has passed quite a comfortable night. Passed urine 
without the catheter with little effort, and with no pain. Pulse 104; soft. 
Skin soft and pleasant to the touch. Tongue slightly furred and moist. 
Says she feels well. Assists herself better, and has very little soreness of 
the abdomen. 10 P. M. Has complained much this evening of pain in 
the head. — Pulse 120, but soft. Skin soft. Drew about four ounces of 
blood from the temples by leeches. Pulse fell afterwards to 100. Entire 
relief to head, and feels very comfortable. Catheterism. 

26th. 9 A. M. Found the patient taking her own breakfast, with the table 
at her bedside. Had a very comfortable night; slept all night; pulse 100. 
9 P. M. Pulse 92 — 98. Had a slight paroxysm of fever this afternoon, 
which appears to be periodical. Ordered 1 gr. extract of bark [Wether- 
ill's] every two hours, when free from fever. 

28th. 10 A. M. Patient did not sleep much last night; complains of un- 
easiness in the head, left hip and groin ; but has a warm moist skin, and 
moist tongue, and pulse ninety-two. The stomach has been quite irritable 
since 5 A.M.; vomiting at times greenish mucus, and distressed con- 
siderably w r ith nausea. The abdomen is soft, not distended, free from pain 
and soreness. The irritability of stomach was supposed to be owing to some 
badly cooked prunes she had eaten the day before yesterday. Catheterism. 
Applied a spice plaster to the gastric region. Ordered a teaspoonful of 
magnesia in camphor water, wine whey, and occasional doses of aqua am- 
monia. 2 P. M. Gastric distress diminishing. Enema brought away some 
feculent discharge, containing prune skins. -Skin moist and warm; pulse 
94. Ordered two teaspoonfuls of magnesia. 9 P. 31. The gastric disturb- 
ance has been gradually subsiding, and is now entirely gone. Has had 
several discharges from the bowels containing prune skins. Complains of 
some disturbance of the head, and good deal of heat, there being slight 
febrile excitement. Note. The patient had taken a dose of elixir of opium 
soon after having eaten prunes, which is supposed to have suspended diges- 



1848.] Atlee on Excision of the Cervix Uteri. 91 

tion. Being retained in the stomach and bowels, they were a source of 
irritation until discharged by medicine. 

2,9th. 9 Ji. M. Has had a comfortable night. Bowels opened ; no fur- 
ther evidence of undigested prunes. Pulse 90, soft; skin good; tongue 
moist and less furred. Complains of some confusion of head. 9 P. M. 
Pulse 87 — 100. Passed a good day; washed out the vagina with flaxseed 
tea and creasote,which brought away several small particles of dead tissue 
imbedded in muco-purulent discharge. A teaspoonful of the following 
mixture was ordered every two hours. R. — Emuls. acac. arab. 5j ; pilul. 
casrul. grs. iv. — M. 

30th. 10 A. M. Rested tolerably well last night without an anodyne, 
excepting that she had a feeling of pressure on the bladder and a desire to 
urinate oftener than usual. Pulse 88 — 94; skin soft; tongue cleaner; 
washed out of the vagina more of the sphacelated tissue. Catheterism 
Complains of cerebral disturbance. Ordered blisters behind the left ear. 
9 P. M. Head and bladder better. A discharge of laudable sanguinolent 
pus. 

Jan. 2d, 1847. 10 A. M. Has been geiting along very well. Examined 
the wound with the speculum for the first time since the operation, Dr. 
Morton being present. The uterus is more elevated than before, the cut 
surface looks quite healthy, and is coated with lymph, and the lining mem- 
brane of the vagina has a healthy aspect. A slight abrasion of the wound 
was made by the speculum. 

3d, 10 A. M. Passed a restless night in consequence of a noisy house 
[hotel].- Feels weak and exhausted. Ordered one grain of citras quin. et 
ferri three times a day, and occasional doses of assafetida. 

8th. Examined the wound, is in good condition. Has used animal food 
daily for the last week. 

11th. Wound looks well. Applied nitrate of silver to induce more rapid 
cicatrization. Dr. McClellan present. 

14th. Patient has been sitting up these two days. Examined per vagi- 
Dam et rectum. The uterus still somewhat retroverted. 

16th. Wound looks healthy. Applied nitr. arg. ; and again on the 23d. 

31st. Up to the present date, I washed out the vagina myself daily with 
flaxseed tea and a solution of creasote. After this it was attended to by 
the nurse. 

Feb. 2d. The application of the caustic to-day was accompanied with 
some bleeding. Supposed menstruation. 

bth. Some sanguineous discharge from the vagina, which, having been 
preceded and accompanied by the ordinary menstrual symptoms, was con- 
sidered as catamenial. 

8th. Examined per vaginam by the toucher. The finger was stained with 
blood. The cut surface felt smooth and even. 

14th. Examined through the speculum. The surface of the wound was 
disposed to throw out granulations, which, however, had a healthy aspect, 
but were too much elevated in the centre of the wound. Slight bleeding 
while examining. 

17th. Examined the wound with Dr. McClellan. Its surface was be- 
coming more prominent. The speculum employed to-day was glass, and 
was made by cutting a conical lamp chimney into sections of about four 
inches long, which answered the purpose admirably. While the speculum 
was in situ, the surface of the wound was well covered over with the acid 
nitrate of mercury, afterwards penciled with a stick of vegetable caustic, 



92 Atlee on Excision of the Cervix Uteri. [July 

a portion of which was also powdered and passed up against it upon some 
lint. The speculum was now stuffed with charpie, and the whole retained 
in position by the T bandage for about four hours. 

18th. Examined the wound. Surface remained coated with caustic. 
Dr. Morton present. 

24th. The granulations have increased; the wound has become more 
elevated in the centre, so as to make a rounded projection. Drs. McClellan 
and Morton being present, it was agreed to apply the caustic more effectu- 
ally. In using the vegetable caustic this time, I continued applying the stick 
to the parts until it was melted down to a very sharp point. By means of 
this point I was able to penetrate into the substance of the structure just as 
readily as with the knife, and I continue to do so until I had completely 
disintegrated the whole of the diseased surface. The vagina was perfectly 
protected by means of the speculum. The speculum being stuffed with 
lint, it was retained for several hours by the T bandage. The lint having 
been first withdrawn, and the parts well syringed off with vinegar and 
water, the speculum was removed. In neither application of the vegetable 
caustic was there much suffering. 

28th. Complains of considerable soreness of the vagina. Examined it ; 
found it a good deal inflamed. An injection of a solution of sugar of lead 
and opium was used every two hours until it was relieved. 

March 3d. Examined per vaginam. Inflammation much relieved. The 
lower surface of the uterus covered with sloughs, and the granulations all 
destroyed. 

10th. The patient has been attacked with acute inflammation of the right 
kidney. She says that this is the third time that she has been so affected, 
twice previously to the operation. Cupping and leeching relieved her very 
much. Sloughing of the wound is going on well. 

llth. In consequence of the uterus having become quite elevated, and 
the vagina contracted and elongated, the nurse could not so satisfactorily 
syringe off the sphacelating surface of the wound. I therefore again at- 
tended to this matter personally, and daily washed the wound through the 
speculum, and also detached the sloughs by means of the forceps as they 
became looser. 

22d. The injections through the speculum have been continued daily. 
Sphacelation is nearly completed, the wound being nearly clean. There 
has been no bleeding since the last cauterization. The granulations have 
not sprung up again. All the parts seem in the most favorable condition. 
Drs. McClellan and Morton examined the parts with me to-day. All 
pleased. Applied the nitrate of silver lightly, to favour cicatrization. 

25th. Ever since the nephritic attack, Mrs. W. has had something like 
remittent fever, with paroxysms at night. Her tongue has become red at 
the point, and is covered with a harsh fur towards the back part. Con- 
siderable gastric and intestinal irritation — flatulency — and globus hystericus. 
The distress being so great to-day, a blister was applied over the epigas- 
trium, and one grain of blue mass was ordered every two hours through 
the day, and valerian at night. 

2Qth. Much relieved. Passed a comfortable night. We again all ex- 
amined the wound ; looks well. The nitrate of silver was applied to a 
small raw surface. 

There has been a discharge of pure laudable pus from the vagina ever 
since sphacelation commenced after the last application of the vegetable 
caustic. 



1848.] 



Atl£e on Excision of the Cervix Uteri. 



93 



30th. The patient has complained for several days of a very uneasy sen- 
sation in the larynx, and has a constant tendency to screatus or clearing-out, 
expectorating occasionally a portion of inspissated mucus. A spot tender 
to pressure was found upon the right side of the larynx. Ordered a blister 
as large as a shilling to be applied over it. This drew well, and afforded 
relief. She also received considerable relief from inhaling the following 
mixture. R. — Iodin., grs. vj; fol. cicutse, grs. xij ; asth. sulph. rectif. ^i. 
M. 

•April 3d. Examined the wound ; looks very healthy. The discharge 
consists of laudable pus, free from smell. The vagina is perfectly healthy 
in its aspect; has considerable tone, and is contracted. 

14th. The patient was alarmed this evening by a large amount of healthy 
pus which flowed from the vagina,* while in the act of defecating on the 
chamber. It was explained by supposing that an accumulation of pus had 
occurred in the upper part of the vaginal tube in consequence of a re- 
cumbent posture for forty-eight hours, there being, as it were, a cavity to 
contain it between the superior termination of the vagina and the body of 
the uterus in consequence of the absence of the tumour and of the os and 
cervix uteri. 

24th. The wound has been examined regularly every two or three days. 
To-day Drs. McClellan, Morton, and myself examined it for the last time. 
The examination was carefully made through the speculum. The wound 
had a beautiful, smooth, even surface, and perfectly healthy aspect, and 
appeared covered with a thin epithelium. The os and cervix uteri were ab- 
sent, and the body of the uterus below was excavated so as to form a hollow 
cone with apex above. The walls of the uterus, forming the base of this 
cone, were continued into the upper end of the vaginal tube. The vagina 
and external genitals were considered in a healthy condition. We several- 
ly expressed ourselves gratified with the favourable condition of the parts. 

The patient's general health during the winter has not been good. She 
has been more or less annoyed with neuralgic, rheumatic and dyspeptic 
symptoms. Her pulse was generally eighty-four, but ranged as above 
stated. Tongue occasionally reddish at the end and edges, with a whitish 
fur; generally, however, it looked well Although evidently cachectic, she 
is better in these respects, begins to relish food, and is preparing for her 
journey home to Pittsburgh. 

May 4th. Mrs. W. left Philadelphia to return home. On the 8th, a 
telegraphic dispatch, dated at Pittsburgh, was received, saying that she ar- 
rived safely the evening before, was very glad to see her friends, and her 
friends rejoiced to see her. On the lOth^another message by telegraph 
made the melancholy announcement that she had died at 9 o'clock the pre- 
vious evening [Sunday], A post-mortem examination was immediately 
requested by telegraph, but was refused. 

Remarks. — I offer no comment upon the above interesting case. The 
account is purely clinical, the notes having been made at the bed-side of 
the patient, and abridged to suit the pages of the Journal. 

I refer your readers to the following authorities on this subject, viz : — 
Duparque on the Uterus, p. 351 ; Colombat on Diseases of Females, Prof. 
Meigs' edition, 1845, p. 327; Lee on Tumours of the Uterus and Ap- 
pendages, pp. 95-108; Lever on Organic Diseases of the Uterus, p. 210; 
Ashwetl on Diseases of Women, Goddard's edition, p. 295; Simpson on 
Excision of the Cervix Uteri for Carcinomatous Disease, Braithwaite's 
Retrospect, American edition, 1847, part 14th, p. 294. 
No. XXXI.— July, 1848. 7 



94 Wallace, Dissection of a Fungus Hsematodes Oculi. [July 



Art. VII.— Dissection of a Fungus Hsematodes Oculi. By W. Clay 
Wallace, M.D., New York. 

To harden the tumour before examination, it was macerated in an alco- 
holic solution of corrosive sublimate, and after repeated washings it was 
again macerated in a solution of chloride of zinc. On separating the 
fissures at the apex, a number of small reddish stems similar to those sup- 
porting the minute flowers of a cauliflower, were seen to arise from the 
mass and support some of the crusts of the fungus. The tumour was 
opened mid-way between the apex and the optic nerve, and the encepha- 
loid matter scraped away until the specimen was considerably injured 
before observing the principal stem. 




Fig. 1 represents the tumour as it appeared after the removal of a por- 
tion of the encephaloid matter. The principal stem or trunk was firm as 
tendon, and hollow when opened longitudinally. At nearly two inches 
from its origin, the trunk divided into several branches from which, and 
from the trunk itself, the medullary matter proceeded. When the latter 
was examined with a microscope, it was found to consist of a series of 
fibres, and granules, as represented at fig. 2. Some of the granules (fig. 6), 
which had fallen to the bottom of the fluid in which the preparation was 
immersed, exhibited on the application of a higher magnifying power, 
nuclei and irregular extremities by which they had probably been attached 
to the fibres. Fig. 3 is a magnified view of a transverse section of the 
stem at 3 in the first figure. Fig. 5 if a similar section at 5, where it is 
divided. Fig. 4 is a magnified longitudinal segment. 

The appearance of the preparation, which I still possess, favours the 
opinion that fungus haematodes belongs to the class of parasites, as ad- 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 95 



vanced by Kluge and Meyen, who have endeavoured to show that the 
encephaloid tumour possesses a vascular system of its own. 

It has been observed the fungus was mutilated during the examination ; 
this account will, therefore, be regarded as a very imperfect contribution to 
the pathology of this deplorable disease. 



Art. VIII.— Occlusion and Rigidity of the Os Uteri and Vagina. By 
James D. Trask, M. D., Whiteplains, Westchester Co., New York. 

Among the causes of rupture of the womb, enumerated in our mono- 
graph on that subject, in the last two numbers of this Journal, obliteration 
and extreme rigidity of the os uteri and of the vagina, were alluded to as 
of occasional occurrence. In connection with that inquiry, we collected all 
the instances that were within reach, of labours in which these complica- 
tions were met with. This subject has received but little attention from 
medical men, and few text books on obstetrics make any allusion to it as a 
source of difficult labour, or to the treatment of this class of cases. Among 
those authors who refer to it, a considerable difference of opinion exists, as 
to the proper course to be pursued when such complications are met with ; 
some appear to discountenance any intervention by operative procedure, 
while others, of equal respectability, recommend an early resort to division 
by the knife, of the occluded or strictured parts. 

Most of the cases of reputed occlusion of the os uteri, are regarded by 
Baudelocque, Velpeau, Dewees, and Denman, as instances of undetected 
malposition of the uterus, by which the cervix is thrown backward to the 
sacrum, or to the one or the other side of the pelvis, and beyond reach of 
the finger. That error from this source has, in some instances, induced 
the attendant to make an artificial opening into the womb, the os being 
patent, but inaccessible, there can be no doubt ; inasmuch as well attested 
instances of it* are recorded by Baudelocque and others. 

We have thought that a series of cases of complete and partial oblitera- 
tion of the os uteri and of the vagina, might prove instructive ; as showing 
the consequences of neglect, the advantage gained by judicious interference, 
and as affording assistance in determining on the right course to be pur- 
sued. 

1. Cases of Complete Occlusion of the Os Uteri. 
Case I. — An Irish woman, stout built, setat. 28. Two years before, she 
fell down stairs at the fourth month of her first pregnancy, and at once had 



* Mr. North, in Lond. Med. Gaz. } vol. xx. p. 392. 



96 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



flooding and pain, which lasted two days. Instruments were applied, and 
the patient delivered, during which she suffered great pain, and had dread- 
ful flooding, fainting, and depression. A discharge of pus succeeded, and 
lasted until the second pregnane}'-. 

The physician was called at noon. She had had strong pains since the 
preceding evening, but no show. The pains were urgent and powerful, 
forcing low down into the vagina, a dense, globular tumour, consisting of 
the head covered by the uterus. No os uteri could be felt, but where it 
should be, a firm hard point with three ridges diverging from it. Opiates 
were given, which almost entirely put a stop to the pains during the after- 
noon and night. Pains returned at 7 A. M., powerful, and rupture of the 
womb was feared. While the finger rested on the central part, something 
was suddenly felt to tear, and after two pains the finger was passed into the 
rent. This enlarged in the direction of the three cicatrices, and by 5 P. M., 
the opening was so large, that the membranes burst. The head did not 
advance for three hours; giddiness and headache came on; she was de- 
livered by forceps of a full-sized, living child. She was well in ten days, 
with a slight purulent discharge, which left her in one week afterward. — 
Dr. Wright, from the Montreal Med. Gaz., in Lond. Med. Gaz., 1846, 
p. 688. 

Case II. — iEtat. 40 ; good constitution ; the mother of three children, the 
last having been born eight years before. Anteversion of the womb had 
been supposed to exist, and a pessary recommended. 

At 6 A. M. she had been in labour thirty hours. No os uteri could be 
found with a probe or finger. The vagina was five inches in length, dry 
and swollen. The pains were regular and active. At 8 o'clock, A. M. in 
consultation, 4 P. M. was fixed for the performance of vaginal hysterotomy. 
The pains then not being very severe, it was deferred until 11 P.M. With 
a blunt pointed bistoury, an incision was made, of half an inch in length, 
layer by layer, through the uterus in the line between the bladder and rec- 
tum, and four ounces of liquor amnii escaped. This was crossed at right 
angles by another. There was no pain, or hemorrhage in the operation, 
and in one hour the child was born alive. 

After the lochia ceased, a bougie was introduced frequently for some 
time. The aperture is now small and irregular, without a cervix. The 
catamenia returned in six weeks. 

During the early months of gestation, she frequently injected strong lye 
of ashes, and even into the cavity of the womb (?) by a gum catheter, and 
at each lime felt intolerable pain and also observed suppuration and detach- 
ment of the skin. — Dr. Caffe of Paris, from Journ. Hebdom.. in Arch. Gen. 
See Ryan's Journ., vol. vi., p. 87. 

Case III. — In the first labour, the head was impacted, and the vectis em- 
ployed. In the second labour, the pains were active for twenty-four hours, 
and for four or five hours, excruciating. No os uteri was detected by the 
midwife. The os could now be felt, the size of a sixpence, and the space 
within the circle was extremely thin and tough, thinner than the surround- 
ing uterus, hermetically sealing the womb. This membrane was divided 
with a gum-lancet, and in four pains the os was so dilated as to admit the 
head. The pains now became slight, ergot was given, and the vectis used. 
—Mr. Tompkins, Lond. Lancet, 1831-2, vol. i. p. 749. 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 97 



Case IV. — >Etat. 36, first child. The waters had dribbled away; no 
orifice was discoverable. On the descent of the head covered by the ute- 
rus, a thin portion was felt. A female catheter was passed through this, 
and then the finger. It tore like a thin membrane, the os dilated, and in an 
hour and a half, labour was terminated. — Dr. Felix Hatin, in IS Experience, 
Mai, 1839. See Brit, and For. Rev., vol. ix. p. 263. 

Case V.— ^Etat. 23 or 24, Irish, first child. At 7 P. M. she had been 
in strong pains since the preceding evening, but there was no show ; pains 
urgent and powerful, and no os to be perceived after several hours. At 2 
P. M. a firm, globular mass was forced into the vagina by every pain, but 
there was no break in the surface. For several hours more, the pains were 
unusually severe ; castor oil was given. Where the os should be, there 
was a minute point, somewhat thinner than the surrounding parts. 

She had menstruated for fourteen years; discharge, pale and scanty ; no 
catamenia since her marriage, nine months before. A copious reddish 
discharge took place three days before labour. The pulse was 120, 130, 
and very irritable ; pains violent; skin irregularly hot and cold; features 
anxious. The point referred to was punctured, and an incision made to- 
ward the bladder, and towards the rectum, of one and a half or two inches ; 
the last incision was followed by a few drachms of dark blood. The inci- 
sions were not made laterally, for fear of wounding- the arteries of the neck. 
Operation produced no suffering; pains abated a little, and returned. At 
4 A. M. next day, under a strong pain, the edge of the incision tore sud- 
denly to the right side, and soon afterward, during an examination, the 
other toward the left sacro-iliac junction, both without hemorrhage. She 
became faint; pulse 140, 150, and stimulants were required. In two hours, 
powerful pains recurred, and the head was born at 11 A. M. The pains 
becoming inefficient, stimuli were given. The child was born alive, and 
the mother recovered. The vagina was very short after recovery. There 
was no cervix, but a puckered, irregular orifice, admitting the tip of the 
finger, with three cicatrices radiating from it. The left mamma had no 
nipple. — Mr. Tweedie, Guy's Hospital Reports, vol. ii. p. 258. — [For a 
continuation of this, see Case XXII.) 

Case VI. — Three and a half years before, had twins; labour natural; 
but followed by puerperal fever,(?) from which she never entirely recovered. 
A putrid discharge continued for several months, and afterward appeared 
in the place of catamenia for two and a half years, when the menses ap- 
peared, and conception took place. The cervix had sloughed away, and 
the husband (a physician) now discovered that the os had become closed 
by an indurated membrane, which resembled a pig's bladder. 

She was, as she supposed, three weeks beyond nine months, and had 
not felt the child for some time. There had been slight pains a few days 
before, which continued, but did not increase. Next day, Dr. Blundell 
detected a tendency to a dimple at the side of the os, and introduced a 
small sound through it. Soon afterward, she had violent bearing down 
pains. At midnight, there had been some discharge, but no opening was 
perceptible. The pulse was very rapid, and a most profuse perspiration 
broke out. She was left, and seen again at 10 A. M., and was then a little 
more collapsed. At noon, the os was found open, but the edges jagged, 
with a flap of tough, granular membrane, hanging from the posterior mar- 
gin. Collapse increasing ; the hand was introduced, and the child delivered 



98 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



by version. Slight hemorrhage followed the removal of the placenta, and 
she died in a half hour afterward. The child appeared to have been dead 
for some days. — Mr. Waller, reported by Mr. Tweedie, in Guy's Hosp. 
Reports, vol. iv. p. 120. 

Case VII., VIII. — In both, the os was normally, exceedingly small, and 
the occlusion was produced by cellular membrane filling up the orifices. 
The lower part of the uterus was rendered tense and hard, so as, in one 
case, to resemble the bag of membranes. Case VIII. was fat and plethoric, 
and although bled four times, blood flowed from the mouth and nose at 
every pain, and she had been in labour eight days. Case VII. was in la- 
bour two days and nights. In both, the membrane was punctured by a 
female catheter — there was no laceration ; delivery without assistance ; 
children living. — From Naegele's Thesis. See Ibid., p. 137. 

Case IX. — iEtat. 35; second labour; pains were felt August 14; the 
next day no os could be discovered, by the midwife or a surgeon who was 
called in, though the uterus was forced low into the vagina. In the even- 
ing of the 16th the pains were less frequent and strong, and she was deli- 
rious at night. When seen on the morning of the 17th she was exhausted 
and worn out. The womb, stretched over the head and attenuated, was 
pushed almost to the mouth of the vagina, but no os was perceptible. The 
scalpel was then used for making an os. She was delivered of a dead 
child by forceps, and died in the evening at the end of nearly three days. 
— Ibid. 

Cases X., XI. — The os in both closed by a membrane united to the mar- 
gin of the aperture. In one, the finger was introduced ; in the other, the 
point of a female catheter — instruments were used in neither — both children 
were alive, and both mothers recovered. — Ibid. 

Case XII. — First pregnancy, during the whole of which she suffered 
from leucorrhcea. Labour commenced August 25th. There was no os, 
and on the 27th one was made by incision. Six hours afterward, she was 
delivered of a living child by forceps. Recovered well — the_ os retained 
the form of the incision — and the next labour was natural.— Ibid. 

Case XIII. — iEtat. 42; first pregnancy. Labour began May 2d; no os 
could be found. On the 4th an os was made by incision, and in twenty- 
two hours was delivered by forceps. — Ibid. 

Case XIV. — After miscarriage, extensive sloughing took place, embrac- 
ing the os, leaving a contracted circle as a cicatrix. The head descended 
low, pushing the lower part of the uterus before it. After a considerable 
time, the strength being almost exhausted, a puncture was made by a bis- 
toury, and an incision of considerable extent. The head was forced through, 
rending at right and left. Some alarming symptoms arose — the head was 
perforated and she was soon delivered. She recovered, and became preg- 
nant again. — Ibid., from Br. Gooch's Lectures. 

Case XV. — First pregnancy. No orifice could be discovered to the 
womb notwithstanding most careful examinations. The vulva was occu- 
pied by a solid body which distended it. A consultation failed in finding 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 99 

any opening to the womb. Convinced that the mother and child were in 
great peril, they decided to make an opening at the place of the os uteri. 
It was on the point of suffering a rupture. There was already a rent, in- 
volving a part of the thickness of the walls. This was the spot selected. 
Labour terminated spontaneously, and after it no cervix or os could be dis- 
covered. After two months the opening closed itself by degrees, and no 
accident followed the operation. — M. Lauverjat. See Diet, des Sci. Med., 
vol. xxiii. p. 301. 

Case XVI. — Had been in labour fifteen or sixteen hours. Although 
the head was in the cavity of the pelvis near the vulva, no os could be felt 
by the midwife. The pains were very rapid and violent; M. Gautier first 
supposed it an obliquity of the womb, but after very careful examination no 
os could be found. The depth of the vagina was an inch in front, and an 
inch and a half behind. Vaginal hysterotomy was performed, and delivery 
effected by the forceps. There was some hemorrhage, but she soon re- 
covered. 

At the end of six weeks, the womb was very near the vulva, the vagina 
not being over an inch and a half long behind. These adhesions appeared 
to have been caused by a displacement of the womb, following a violent 
effort to vomit, by which the orifice of the womb was carried backward and 
the fundus over the pubes. Inflammation followed, uniting the mouth of 
the womb to the posterior wall of the vagina. — M. Gautier, in Journ. de 
Med. See Diet, des Sci. Med., vol. xxiii. 

Case XVII. — M. Morlaune, of Metz, found the head enveloped in the 
womb, already engaged in the vulva. Notwithstanding most careful ex- 
aminations, in all directions, no os could be discovered. He was satisfied 
that hysterotomy was the only resource, but did not dare to resort to it, be- 
cause the woman was in the sixth day of an ataxic fever, and therefore had 
no hope of saving her. — Journ % tfAccouch., vol. i. See Diet, des Sci. Med., 
vol. xxiii. 

Case XVIII. — iEtat. 30 years. January 11th, at the seventh month, on 
examination, in place of the os was a transverse bridle, seemingly a cicatrix. 

Pains came on April 25th but produced no change in the neck. It was 
hoped that the os might become perceptible and open in the course of the 
labour, especially since a fluid like the liquor amnii tinged with meconium 
appeared. The 26th passed without any os appearing, though the pains 
were powerful and continuous and the head was engaged in the pelvis, 
pushing before it a corresponding portion of the womb. The entire hand 
was employed to explore the vagina to the cul-de-sac, and no opening 
found. After being forty-eight hours in labour, and the strength beginning 
to fail, a consultation determined to practice vaginal hysterotomy. This 
was performed fifty-six hours after the commencement of labour. Pains 
having ceased for many hours, the forceps were employed. Extraction 
was very difficult and the child dead. Recovery was favourable. 

The incision had been made in the anterior wall with the bistouri cache. 
Eight days afterward the opening would scarcely admit a writing-quill. A 
sound was introduced but could not be borne. A small orifice remained, 
through which the menses escaped two months after delivery. — MM. Lob- 
stein, Flamant and CaillcL See Diet, des Sci. Med... vol. xxiii. 



100 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



Case XIX. — The patient, the mother of several children, was taken in 
labour December 18th, 1843, at 7 P. M., and was seen by Dr. Bedford next 
day at 7 P. M. Her pains were violent and she suffered intensely. There 
was obliteration of the os uteri. Dr. B. made a bi-lateral section of the 
uterus, and in ten minutes afterwards the patient was delivered of a living 
child. Both did well without one untoward symptom. The obliteration 
was caused by attempts to produce miscarriage with an instrument. — Prof. 
G. S. Bedford, in New York Journ. of Med., March 1843. 

Case XX. — iEtat. 36; first labour. Physician called at 5 A. M., No- 
vember 6th. Pains were decided and regular, but no os uteri could be 
found on careful examination. At evening the pains had increased and 
become expulsive, but no os could be found by him or by Prof. V. Mott, 
who had been sent for. During the night, nothing but a globular, smooth, 
uniform surface could be felt. Was first seen by Dr. Bedford at 1 P. M., 
November 7th, after having been in more or less active labour for forty 
hours. There was no trace of an os. Dr. B. made a bi-lateral section of 
the cervix, with a probe-pointed bistoury, "to within a line or two of the 
peritoneal cavity," and the head was felt. The substance of the neck felt 
like cartilage. At 6 P. M., no increase of the opening; an incision was 
made in the posterior lip, and tart. emet. given. Nov. 8th, at 2 A. M., 
the incisions were enlarged, and two more made toward the ischiatic bones. 
At 1 1 A. M., opening somewhat enlarged and the parts hot. At 6 P. ]VL, 
strength failed, pulse 140, the head at the brim, the opening of the womb 
not larger than a dollar, rigid and unyielding. Forceps were applied and, 
after great effort, the child was born alive. The mother suffered only from 
inability to pass water for two weeks. Mother and child both well three 
months afterward. — Prof. Bedford, Jimer. Journ. of the Med. Sciences, 
April 1848. 

Case XXI. — Contraction of the pelvis apd cohesion of the sides of the 
os uteri, leaving no vestige of a passage- — the result of inflammation and 
suppuration following previous delivery. 

After a labour of two days the vagina was dilated, which afforded a view 
of the contracted os. An incision a half inch deep was made and the head 
touched. The parts were of cartilaginous hardness, not yielding to pains, 
and requiring several subsequent incisions. The opening not yielding 
sufficiently, perforation was resorted to. High fever followed, and she died 
in twenty-four hours.— See Smellie's Works, vol iii. p. 55. 

We propose to inquire into the causes, pathological condition, termina- 
tion if left alone, different modes of interference, and results of interference 
in this class of cases. 

In two instances, the lesion could be traced to inflammation following 
previous severe instrumental labour; in another, to inflammation, after an 
ordinary labour; and, in another, to inflammation following a previous mis- 
carriage. In one instance it was caused by inflammation succeeding a 
descent of the womb into the vagina, after severe vomiting. In two it was 
the result of attempts to procure abortion, and in one it appeared due to a 
congenital malformation; no cervix being discovered in a subsequent de- 
livery, and the patient having but one mamma, 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 101 



As to the actual condition of the diseased parts, we learn that in case L, 
there was a tense globular tumour forced into the vagina, consisting of the 
head, covered by the uterus. No os uteri could be felt, but in its place 
was a firm point with three ridges diverging from it. 

In Case II. there was considerable thickness of tissue divided by the 
knife, before the cavity of the womb was reached. In Cases IX., XIII., 
XVII., XX., no os uteri was perceptible. Case XII. had suffered from 
leucorrhoea during pregnancy, and there was no os uteri until the knife 
was used — the one thus made retained the form of the incision. Case 
XIV. had had sloughing of the whole cervix, leaving "a contracted circle" 
as a cicatrix. 

In Case XV. there was no os, but rupture had already taken place in 
some of the uterine fibres. In Case XVI. there had been anteversion of the 
womb, followed by inflammation producing adhesions of the vagina and 
cervix, so as to render the os impervious. In Case XVIII. there was a 
transverse bridle, seemingly a cicatrix. In Case XIX. there was oblitera- 
tion of the os and an irregularity of surface where the os should have been. 
In Cases XX. and XXI. the parts felt like cartilage. In most of these 
instances the source of the obstructed condition of the mouth of the womb is 
obvious enough; adhesions having formed, as a consequence of previous in- 
flammation, and the condition itself was recognized by the hardened, irregular 
lines of cicatrization radiating from a single point, or encircling the cervix. 

In several other instances, however, there was a condition of things pro- 
ductive of similar consequences and yet of a somewhat different character. 
In Case III. the os uteri could be felt, of the size of a sixpence, and the 
space within the circle was extremely thin and tough, thinner than the 
surrounding womb, and yet the womb was hermetically sealed by it. In 
Case IV. no orifice was discoverable, but on descent of the head a thinner 
portion of the uterus was felt, through which a female catheter was passed, 
and then the finger, and delivery was soon completed. In Case V. there 
was a minute point, thinner than the surrounding parts, where the os should 
have been. In Case VI. the cervix had sloughed and the os became closed 
by a membrane resembling a pig's bladder. In Cases VII. and VIII. the 
occlusion was produced by cellular membrane filling up the orifice, and 
both yielded to the point of a female catheter. In Cases X., XL, the os was 
closed by a membrane united to the margin of the aperture, which was 
broken through in one case with the finger, and in the other by a female 
catheter. 

The latter are examples of what Naegele has described as "conglutination 
of the os uteri," in a thesis devoted to that subject. The obstruction in these 
cases, though removed by a slight force applied directly to it by a blunt 
instrument, is, nevertheless, such as very seriously to retard labour. Ac- 
cording to Naegele, this closure of the os is due to a false membrane, or fila- 
mentous tissue, possessing a moderate degree of resistance, which he con- 



102 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



siders the result of unsuspected inflammation of the neck of the womb. 
Dr. Ashwell (Guy's Hosp. Reps., vol. iv.), adopts this explanation, and 
in remarking upon it, says, " It is well known, that normally, this orifice is 
sometimes very small; at others, instead of a transverse chink — its most 
usual form — there is merely a diminutive circular aperture. In either of 
these conditions of the orifice, complete obliteration may be easily produced, 
by an amount of local inflammation following conception, which would not 
seriously interfere with the pregnancy or the health of the individual. It 
is important to bear in mind, that such closure may not be attended by any 
other disease of the parts, the adhesions may be firm and complete, but 
there may be no scirrhous induration, no distinct nodule of hard substance ; 
the neck of the uterus will be forced down by the pains ; and the sensation 
imparted to the finger, on examination, during labour, will be quite natural, 
excepting only that no aperture will be found." 

The inflammatory origin of these slighter degrees of obstruction of the 
os uteri is not allowed by some. Thus, Jacquemier, torn. ii. p. 181, asks, 
** Is this a veritable agglutination 1 Is this pretended plastic tissue any- 
thing more than a portion of exuberant membrana decidua ? Do not these 
cases belong rather to some of those conditions of the cervix which render 
dilatation very difficult?" 

The strength of the adventitious substance here deposited, varies, as we 
have seen, from that of cellular tissue, easily broken down, to that of a 
firmer consistence, requiring, as in Case III., a cutting instrument for 
its division. The history of Case VI. clearly points out the inflamma- 
tory origin of the obstructing membrane ; so also in Case III., there had 
been difficulty in a previous delivery, and the membrane occluding the 
mouth of the womb was exceedingly thin and tough, hermetically sealing 
it. In both these instances, it is evident that the obliteration of the os must 
have taken place subsequent to impregnation. In both, it would appear 
that the inflammation of the cervix continued for some time after delivery ; 
long enough for conception to have taken place ; and that it finally termi- 
nated in the production of the false membrane. In Case V"., there was 
probably a congenital defect in the structure of the cervix, as well as pre- 
vious inflammation. The previous history of the remaining cases of con- 
glutination of the os, throws no light on its origin in them. The degree 
of firmness which the membrane possesses, taken in connection with its 
origin in Cases III. and VI., renders it highly probable, that, as Dr. Ash- 
well suggests, it is due to inflammation occurring after conception, which 
does not render itself manifest by any distinct symptoms. 

The diagnosis of obliteration of the os uteri is sometimes a matter of 
difficulty. As we have remarked, many practitioners of experience are 
disposed to deny the probability of its existence, and to attribute reputed 
cases to anteversion, while others, of equal experience, have more fre- 
quently met with instances of obliteration. Dr. Ashwell, in the paper 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 103 



above quoted, says, " he never has met with any seriously protracted la- 
bours from obliquity,"* and yet, indisputable instances of it have been met 
with, in which it was productive of imminent hazard. Great embarrass- 
ment will, at any rate, be felt by the inexperienced, when obliquity exists 
in any considerable degree. 

On failure to reach the os uteri in a vaginal examination, the probability 
of some form of obliquity of the womb would naturally present itself to the 
practitioner. Bearing in mind the different positions which the uterus 
might assume, he would carefully explore the whole pelvic cavity, if by 
chance, the os might be found in contact with the promontory of the sacrum, 
or one of the sides of the pelvis. Under the influence of uterine contrac- 
tion, the head is forced into the hollow of the pelvis, forming a hard, tense, 
globular tumour, on the surface of which, any opening, did it exist, could 
be detected by the finger. If there have been considerable disorganiza- 
tion, the place where the os should be, is recognized by an indurated cica- 
trix, or if there be simple agglutination of the os, there will be a dimple or 
depression below the surface of the surrounding parts, indicating the situa- 
tion of the uterine mouth. 

Our cases, with a single exception, afford no illustration of the result, 
when the patient is abandoned to the efforts of nature. In Case XVII., 
the woman was allowed to remain undelivered, because sick with fever, of 
which alone she might have died. Case VI., however, is a valuable com- 
mentary on the practice of leaving such cases until the powers of the sys- 
tem are exhausted. In this instance, the unfortunate patient lingered 
along from day to day, and sank into a state of collapse from delay in afford- 
ing her proper assistance. 

When the os is obliterated, it is evident that the case must terminate 
either in rupture of the body of the womb, and escape of the foetus into the 
peritoneal cavity, or in laceration of the morbid adhesions, after long con- 
tinued pains, labour being completed with or without artificial aid, as in 
Cases I. and XV., — or in exhaustion and death of the patient undelivered, 
as in Case VI. It is evident that these cases require careful watching 
and judicious management, and it becomes us to inquire as to the proper 
time for interference, and the most suitable means to be adopted. 

Satisfied that obliteration of the os exists, our course will be determined 
very much by the character and degree of the morbid alterations. In cases 
of obstruction arising from the deposit of a thin filamentous or cellular 
tissue, Naegele recommends that it should be broken down by the intro- 
duction of a blunt instrument, as a female catheter, or by the finger. This, 
in Cases IV., VII., VIII., X., XL, was easily effected. The membrane 
occluding the os, although much thinner than the surrounding parts, is 
nevertheless, sometimes sufficiently firm to resist most powerful contrac- 
tions, and to require division by a cutting instrument. In Case III., though 
the pains had been active for twenty-four hours, for four or five hours 



104 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



excruciating, no advance had been made in labour, till the membrane was 
divided by a gum lancet, and then delivery was soon accomplished. In 
Case VI., the membrane was perforated, but a sufficient degree of dilata- 
tion did not take place to allow of version, until she was exhausted by pro- 
tracted suffering. 

Since, then, this membrane must be torn before the head can emerge from 
the womb, we know of nothing to be gained by waiting to see, if perchance 
nature will accomplish the laceration ; and why ought we not, as soon as 
the expulsive pains have clearly revealed this obstruction, to destroy it ar- 
tificially by such means as may be indicated ? We see nothing to be gained 
by delay, or by preparatory venesections, &c. 

If the existence of a comparatively thin, delicate false membrane, can 
cause serious delay to the parturient effort, how much more distinctly is 
artificial interference demanded, when the sides of the os uteri have be- 
come adherent from severe inflammation, and when no vestige of the 
natural structure remains ; when, instead of a cellular tissue that may be 
torn by the finger, or a sound, we have a firmly organized adventitious de- 
posit of perhaps cartilaginous hardness. There can be no doubt, that in 
such cases, an incision should be made into the womb, at the seat of the 
obliterated os. On this point, it is to be supposed, all intelligent persons 
would agree, and its propriety is placed beyond doubt, by the cases we 
have related. The question that would cause most embarrassment, would 
be as to the proper time for interference. Why should not the operation be 
performed so soon as we have satisfactory evidence that such obliteration 
exists ? Are the risks attending the operation so great as the risks attending 
delay ? Have we any encouragement to wait for the employment of vene- 
section, diaphoretics, nauseants, and fomentations ? 

The reply afforded by the cases cited, to these inquiries, is distinctly, 
that nothing is gained by delay, but much periled by resorting to a palli- 
ative course of treatment ; and that the chances of safety to mother and 
child, are much enhanced by an early resort to the vaginal section, before 
the patient's strength has been exhausted by protracted suffering. In 
Cases II., V., XII., XIX., XX., the lives of both mother and child were 
saved. In Cases XV. and XVI., the mothers recovered. In Cases 
XIV. and XVII., the mothers recovered, the children being dead. Cases 
IX. and XXI. were the only instances in which death occurred after vagi- 
nal hysterotomy. In one of these it was delayed until after the patient had 
sunk into a state of extreme prostration, and in the other until after a great 
many hours had elapsed. True, in some of the successful cases, symp- 
toms of exhaustion had begun to manifest themselves, but the importaat 
lesson taught us is, that in almost every instance of occlusion of the womb, 
when let alone, nature proves incompetent to complete delivery; and that 
an artificial opening must be created. In Case I., she succeeded in lace- 
rating the adhesions which had agglutinated the sides of the os, but she 



1848.] 



Trask, Occlusion, etc. of the Os Uteri and Vagina. 



105 



could go no farther, and the uterus being fatigued out, the foetus required 
to be removed by the forceps. A resort to depletory measures has usually 
been advised, previous to the operation ; but the case is widely different 
from that of a rigid, yet patent undilated os. Furthermore, since lacera- 
tion of the parts must take place in order to delivery, incisions should, in 
all such cases be preferred, since it may " perhaps be fairly assumed that 
the risk of unlimited laceration of the uterus and adjacent parts is much 
less, when incisions of tolerable extent have been discreetly made, than 
where merely a diminutive central aperture has been formed." (Jlshwell.) 

To Prof. Bedford of the University of New York, is, we believe, due the 
credit of having first performed the operation of vaginal hysterotomy, in 
this country, for entire occlusion of the os uteri. In both instances, he had 
the gratification of saving the lives of both mother and child. 

The operation is usually performed with a bistoury or scalpel, taking the 
finger as a guide. In Case II., the incision was crucial. In Case V., it 
was made in a line between the bladder and rectum, to avoid the arteries 
of the side of the neck. In Cases XIX., XX., it was bi-lateral. In Case 
II., it stated that there was no hemorrhage or pain ; in Case V., there was 
no " suffering." 

II. Cases of Partial Closure of the Os Uteri. 

Case XXII. (A continuation of Case V.) — In her second confinement 
was taken in strong labour early in the morning of January 2d. The pains 
were most powerful, and by noon there was an opening into the uterus, 
through which the head could be felt, which had not dilated. Half a 
drachm of laudanum was given without effect. At % P.M., the opening 
was irregular, rather less than a penny in area, and bounded anteriorly by 
a strong, firm, unyielding, rigid edge — the cicatrix of former incision, upon 
which the head was forcibly impelled. There was no trace of cervix. At 
6 P. M., no dilatation, pulse quick, skin hot, vagina becoming hot and dry. 
The stricture was divided, with almost no hemorrhage, and without pain. 
Pains lulled and she was faint; brandy and water was given her. In three- 
fourths of an hour there was an additional rent, and delivery soon took 
place. Child asphyxiated, but restored. Recovered in three weeks. — 
Mr. Tweedie, Guy's Hosp. Reps., vol. iv. p. 119. 

Case XXIII. — iEtat. 31. Had extremely rigid os which, after waiting 
twenty-six hours, was dilated by the finger — which process required two 
hours. She died of peritonitis, and the whole cervix, the lower part of the 
body of the uterus, w T ith the vagina, were gangrenous. — Dr. Jishwell, 
Ibid., p. 141. 

i 

Case XXIV. — First labour — eighth month. The os was about the size 
of a half-crown, but rigid and very thin. After continued efforts at dilata- 
tion the os was snipped; the parts gave way — there was much flooding, 
and she died on the fourth day. — S?nellie , s Works, vol. iii. p. 55. 

Case XXV. — Repeated and powerful attempts were made to dilate the 
os, and flooding and fainting were the result. Another attempt was then 



106 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July- 



made, the os feeling as if it were two inches thick. She died in convul- 
sions, undelivered. — Ibid. 

Case XXVI. — A healthy country-woman, setat. 35. A very small ori- 
fice was found, from which there issued a brown mucous fluid. Various 
attempts were made at dilatation and delivery. After two days of protracted 
suffering, she died undelivered, with ruptured womb. — Guy's Hosp. Reps., 
vol. iv. p. 143, from Naegele's Thesis. 

Case XXVII. — First pregnancy — strong and robust — setat. 28. Labour 
began on the 24th, when the membranes broke. On the 27th the os was 
hard and callous. Vapour baths and opiate ointments were employed until 
the 28th, when an incision of one and a half inches was made in the anterior 
lip. Delivery was completed by the forceps, during which the os was not 
torn any farther. The child was dead. She had a favourable recovery. 
— Dr. Burdach, Medicinische Zeitung, 1837. See Brit, and For. Rev., 
vol. vi. p. 235. 

Case XXVIII. — A young girl. On the 6th pains came on and lasted all 
day; the membranes burst in the evening. The cervix was then thick and 
rigid, and the os equalled two centimetres. Next morning it was disco- 
vered to be a face presentation. At 1^ o'clock, P. M., the labour had not 
advanced. The patient was exhausted, and the os was incised on the right 
side, which produced slight relaxation. An incision on the left side was 
followed by copious hemorrhage. Forceps were tried, and also the lever, 
and failed. It was necessary to plug the vagina. At the end of half an 
hour the plug was removed, the os was dilated, and the labour was finished 
by the forceps. She recovered soon. The placenta was supposed to be 
partly over the cervix. — M. Labordie, in the Practice of M. Dubois, En- 
cyclograph. Med., April 1846. See N. Y. Journ. Med., &c, 1846. 

Case XXIX. — M. Caignon was called at 1 1 P. M. She was suffering 
from pains from fever, and was much exhausted. A tumour was felt 
posterior to the vagina, which was supposed to be the head. The os 
was partially dilated, and discharging decidua and fetid blood, and was 
turned toward the pubis. There were symptoms of severe peritonitis. 
Venesection, &c. were practiced. Next day, vaginal hysterotomy was 
proposed. Two days afterward an incision was made, to expose the foetal 
head. The cyst contracted and a pain came on — a living fetus was ex- 
tracted — there was no hemorrhage. Died next day from exhaustion. 

Post-mortem. — Left ovary softened and adherent to the cyst, and this 
was adherent to the uterus. — Arch. Gen., Oct. 1830, from A T . Jlmer. Med. 
and Surg. Journ., vol. ix. 

Case XXX. — iEtat. 36; extremely emaciated and debilitated. Hemor- 
rhage and very fetid discharges from the vagina, from the fifth month. 
Movements of the foetus were very painful whenever it struck the parts 
within the pelvis. The os was two inches in diameter, and at least one 
inch thick. The pains were very violent — venesection — natural birth. — 
Phil. Med. and Phys. Journ., vol i. p. 386, Dr. Sharpless. 

Case XXXI. — iEtat. 40 years. Had strong convulsions at the time of 
accouchement, which lasted two days. She was alarmingly prostrated 



1848.] Trask, Occlusion, etc, of the Os Uteri and Vagina. 107 



The os was of the size of a piece of six livres, and could not be dilated. 
Hysterotomy was the only resource. Hardly had the incision been made 
before delivery took place spontaneously, and though apparently on the 
point of expiring, she rallied and recovered. The child was dead. — Du- 
bosc of Toulouse: see Diet, des Sci. Med., vol. xxiii. p. 297. 

Cases XXXII., XXXIII.— ^Etat. 26 or 27. She had been subjected to 
an operation at the age of 19, for artificial vagina, and just previous to mar- 
rirge, five years before, the os was patent, yet small, admitting the end of 
the finger but totally unlike a natural os. During parturition this did not 
dilate, and was therefore incised in four directions; the head was perforated, 
and labour terminated without laceration — recovery was difficult and pro- 
tracted. In a second labour, a year and a half after this, the os was again 
too small. It was again incised, and the head delivered by the forceps — 
the child was born alive. In neither labour did the os equal a sixpence in 
size, and in both the uterus was forced down external to the vulva so as to 
be in sight. She had three natural labours afterward. — Mr. Butler, by 
Dr. Ashwell, Lond. Med. Gaz., vol. xx. p. 589. 

Case XXXIV. — See Case XCVI. of our series in the January number 
of this journal. The fcetus was forced through the posterior part of the 
uterus into the rectum and expelled from the anus. The os was a firm 
cartilaginous ring. She recovered. 

Cases XXXV., XXXVI., XXXVIL, XXXVIII.— See Cases CVL, 
CVII., CVIIII., CIX., of same series. The cervix was wholly or in part 
torn off by the violence of the pains. All recovered. 

Case XXXIX. — See Case CCVIII. of same series. Neck almost scir- 
rhous — rent at posterior and lateral part of the womb. Died soon. 

Case XL. — See case CCLVIII. of same series. The whole os uteri 
burst off. Died in eleven days. 

Case XLI. — Large and fleshy; third labour; two previous labours very 
severe. When in labour one and a half hours, the os was quite near the 
vulva, with thin edges, about the size of a dollar, perfectly unyielding, and 
apparently a cicatrix anteriorly, extending upwards and outwards. 1 gr. 
of tart. emet. was given and repeated twice at intervals of fifteen minutes, 
producing only nausea. She had already flowed considerably. When in 
labour about two hours and a quarter, the head, covered by the uterus, was 
forced through the outlet and pressed upon the vulva, so as to be distinctly 
visible. There was imminent risk of laceration. The posterior part was 
incised to the depth of an eighth of an inch. The wound instantly en- 
larged itself, and in about three-fourths of an hour the child was born alive. 
She recovered. — Dr. Buckminster, Am. Journ. Med. Sci., Oct. 1847. 

The causes of partial, like those of complete closure of the os uteri, are, 
inflammation from injuries received during previous deliveries or from 
other mechanical causes, and also organic disease. 

Rigidity of the os is met with in every degree, from the not uncommon 
rigidity associated with firm fibre, to that depending on alteration of struc- 



108 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



ture. It is not our purpose now to discuss the subject of ordinary rigidity 
of the os uteri. Ample directions for our conduct are found in most of the 
text books on midwifery, and it is but rarely that a case is met with that 
does not yield to the combined effects of venesection, tartar emetic and 
opium. Our object is^to consider the proper treatment of cases which do 
not yield to these measures; whether the rigidity be due to a seeming in- 
disposition in the structures to dilate, or to morbid changes, the result of 
inflammation, or to malignant disease of the cervix. 

There may be no indication of organic change, and yet the os surrounded 
by a substance entirely undilatable. Thus in one of F. Ramsbotham's 
cases in a second labour — the first having been entirely favourable — the 
pains were exceedingly violent, and after a labour of fifty hours, the os 
equalled only a shilling in size. At this time, during a careful examination 
by the finger, the os was rent and she died on the fourth day of inflamma- 
tion of the womb. When we have met with a case of obstinate rigidity of 
the os uteri, which, has not yielded to a judicious trial of the agents ordina- 
rily employed, what course is to be pursued? We have but three to choose 
from, viz: abandonment to nature, artificial dilatation, and incision. 

The results of an abandonment to nature are the same as when the os 
is completely obliterated. In patients XXVI. and XXXIX. the patients 
died undelivered, from rupture of the womb. In Case XXXIV. there was 
laceration of the posterior wall of the womb, and of the rectum, and expul- 
sion of the foetus per anum. In cases XXXV., XXXVI. , XXXVII., 
XXXVIII., the cervix was wholly or in part torn off — the patients recover- 
ing. In case XL. the whole os was torn off and the patient died. F. 
Ramsbotham relates a case in which the os uteri had entirely sloughed off, 
in consequence of the strong pressure to which it had been exposed for a 
great length of time. 

Cases XXIIL, XXIV., XXV., XXVI., afford no encouragement for the 
trial of artificial dilatation. Its adoption in each of these led to disastrous 
results, and so far as we are acquainted, the whole weight of obstetrical 
authority is against a resort to it. Our only resource, then, is a section of 
the rigid os. 

To determine the proper time for the performance of this operation is 
probably more difficult than when complete obliteration of the os exists. 
In the latter case, the knowledge that an opening must be made by nature 
or art, and the conviction that art can make one with more discretion as 
regards the time, place and extent, will induce one to resort to it early 
and avoid the risks attendant upon delay. But in obstinate rigidity of the 
os, especially when unaccompanied by any distinct organic lesion, it may 
be more difficult to determine the proper time for interference. The dura- 
tion and character of the labour, condition of the patient, both local and 
general, must all be considered : hence the responsibility of each case must 
in an eminent degree rest with the attendant. 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 109 



We shall see by Cases XXII., XXVIL, XXVIII., XXXI., XXXII., 
XXXIII., XLI., that the operation, when resorted to in season, is attended 
by the most favourable results. The incision, so far from leading to more 
extensive and dangerous lacerations, under the continuance of pains, in 
none of these instances encroached on the peritoneal cavity; and being 
made in the most favourable directions, lead to no injury of the adjacent 
organs. The operation was, in the instances in which this point is alluded 
to, almost free from pain and loss of blood. In the only fatal instance we 
have found, the operation was resorted to three days after the patient was 
found "suffering from pains and fever and much exhausted." In some 
of the successful cases, the operation was deferred until symptoms of ex- 
haustion began to manifest themselves, but they nevertheless rallied. 

Bearing in mind the danger incurred by the patient, of rupture of the 
body of the womb, of unlimited laceration of the cervix, and, it may be 
of sloughing, that may follow long-continued pressure; and, considering 
that the risk attendant upon judicious incisions is very little, are we not 
encouraged to an early, rather than a deferred, resort to a section of the 
neck? In the measures usually adopted there is often no inconsiderable 
risk. Biood-letting, to produce any effect must be liberal, and we know 
that many constitutions do not well bear the loss of blood. Where the 
patient is robust, and the fibre firm, general depletion and nauseants, by 
producing relaxation of the general system may diminish local rigidity. 
But in the delicate and anaemic, venesection to any considerable extent 
could not be borne, and in such, a division of the parts must be made at an 
early period. 

We think it may be fairly questioned, whether, after a moderate blood- 
letting and the use of tartar emetic, in case the rigidity does not yield, and 
any structural lesion can be detected, we ought to wait until symptoms of 
approaching exhaustion appear. Should not the occurrence of local heat 
and dryness, or of constitutional sympathy, be a signal for extending help? 
In Case XL. the woman had been in labour less than three hours, the va- 
gina, &c., but a little while before, at least, were perfectly moist and dis- 
tensible, and yet the incision was undoubtedly made at just the right time. 

Since a spontaneous laceration of the rigid parts is the best that can be 
expected after a judicious use of relaxant measures has failed, what is to 
be gained by waiting until the patient is in a state of hopeless prostration 
before the knife is used? Our cases are too few to furnish statistics, of 
authority on this point, but they decidedly favour an early resort to division. 
There is a chance of safe delivery if left alone; but this chance is so much 
less than that after an early incision, that we would not feel justified in wait- 
ing long after a prudent trial of relaxants. 

When obstruction of the os arises from malignant disease, it would 
appear that a resort to division is justifiable, earlier than in the cases we 
have been considering. Laceration is almost certain to take place, unless 
No. XXXI.— July, 1848. 8 



1 1 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



an incision be made, and much suffering endured, when the greater portion 
of the circumference is implicated, or the disease far advanced. It would 
be interesting to learn the influence of an incision on the subsequent pro- 
gress of the disease, when the operation is performed on it in its early 
stages. Whatever it may be, an incision will, in almost every instance, be 
necessary to secure the life of the child, and probably of the mother. 

In the proceedings of the Royal Med. and Chirurg. Society, J. M. 
Arnott, Esq. reports a case in which the morbid growth occupied the ante- 
rior lip and right side of the womb, and equalled a large green walnut in 
size. The diseased mass and contracted os uteri were forced down almost 
into view, when a pain came on ; hooks were fixed in the tumour, which 
was excised by a succession of strokes with curved scissors, and scarce any 
blood lost. The os immediately dilated, and in a quarter of an hour a 
living child was born. The mother recovered, and was well for several 
months. She died sixteen months after confinement, of the disease. — See 
Lond. Med. Gaz., Dec. 1847, p. 1068. 

According to Jacquemier, torn. ii. p. 176, of twenty-seven cases collected 
by M. Puchelt, five died during labour, nine a short time after confinement, 
ten recovered from confinement, and of the rest the result is unknown. 
Fifteen of the children were dead and ten living. 

III. Cases of Occlusion and Contraction of the Vagina. 

Case XLII. — This patient had laceration of the bladder and vagina in 
severe labour, and in consequence, almost complete obliteration of the 
vagina. Eight years afterward, it presented in labour, a firm cicatrix, two 
inches from the orifice of the vagina, with a small perforation leading to 
the womb, the vagina beyond being perfectly healthy. After some delay, 
the stricture was divided in several places — the head descended — the pel- 
vis being small, the head was perforated. During delivery the bladder 
and vagina were rent again, but healed afterward. — Prof. McNaughten, 
N. York Med. and Phys. Journ., No. xxiv., 1827. 

Case XLIII. — The vagina was completely obliterated — four fingers 
breadth. An incision was made in its course, following a fistulous passage 
from the vulva to the uterus. The urethra was wanting — the child was 
expelled. — Lond. Lancet, 1827-8, vol. i. p. 885, from Arch. Gen., Oct. 
1827. 

Case XLIV. — Called to a primipara, in labour from one evening to the 
next. The head was far down, resisted by a thick vertical septum running 
from the recto-vaginal to the urethro-vaginal septum, around which the 
finger could be passed in and brought out. Ergot was given. The sep 
turn formed a band over the head, grew thinner, and snapped like a whip. 
— Lond. and Edin. Monthly, 1844, p. 801, from V Experience, April 
1844. 

Case XLV. — Robust, aetat. 26 ; second labour. There was complete 
obstruction of the vagina a little above the mouth of the urethra, by a 
dense, striated membrane; the striae radiating from the centre, as tense 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina, 111 



cords. An orifice admitted a common probe. The pains were expul- 
sive for several hours. At noon, a crucial incision was made through 
the membrane, which was thick, and tough, like tendon. At night, the 
head pressing on the perineum, and the soft parts being unyielding, the 
forceps were tried, and failed. Perforation was required; the head and 
shoulders offered great resistance ; child unusually large ; had a favourable 
recovery. She had been much injured in a previous labour. — M. Davi- 
zac, in N. Orleans Med. Journ., March, 1845, p. 431. 

Case XLVI. — Third child. A membranous septum existed, across the 
vagina. In its centre was a small aperture admitting a small probe, through 
which the liquor amnii was discharged. This membrane was divided, and 
the patient safely delivered. The previous labour had been tedious. — Dr. 
Richardson, Transylvania Journ. Med., 1829, in Jimer. Journ. Med. 
Sci., vol. iv. 

Case XLYII. — Mother of four. She had injected sulphuric acid into 
the vagina, to procure abortion. Severe inflammation followed, and oblite- 
ration of the upper two-thirds of the vagina. She went to the full time. 
After thirty-six hours' labour, an unsuccessful attempt was made to open a 
passage by the knife, and she died. The womb was rent for four or five 
inches on the left side. M. Lombard, Rev. Med., April, 1831. See 
Jimer. Journ. Med. Sci., vol. iv. 

Case XL VIII. — iEtat. 23. Her previous labour was severe. A stric- 
ture was now observed two and a-half inches within the vagina, and com- 
pletely encircling it. It could be dilated to the size of a dollar; pains 
regular ; ergot was given, and they became very violent ; was bled largely 
to no purpose. The stricture w T as divided upwards and outwards ; a dose 
of morphine given, and she rested during the night. Ergot was given in 
the morning, and she was delivered after a few hours of severe labour. 
Subsequently had loss of control of the bladder and bowels. — Dr. Wil- 
liams, Jimer. Journ. Med. Sci., vol. xi. 

Case XLIX. — iEtat. 27. Had a very difficult labour two years before, 
followed by inflammation, and by closure of the vagina, which admitted 
only a goose quill. During labour, this membrane opposed the progress 
of the head. After six hours, the margin was divided for an inch on the 
left side, and at the end of an hour, one on the right side. The waters 
were black and offensive. She became faint, and the pains infrequent. 
She was safely delivered by forceps, of a living child. In her recovery, 
care was taken to prevent the formation of new adhesions. — Dr. Hoiller- 
mein, Amer. Journ. Med. Sci., vol. xv. p. 407. 

Case L. — A contraction of the vagina, in consequence of a violent 
labour, w T hich scarcely admitted the point of the finger, it being a thick, in- 
durated cicatrix, and a callosity of the perineum that prevented her sitting 
down. After the first stage of labour, forty ounces of blood were taken, 
and she was safely delivered. — Dr. Hamilton's Pract. Observations, Ap- 
pendix. 

Case LI. — Had a violent labour, followed by vaginitis, &c. In labour, 
five years afterward, a callous cicatrix, of the thickness of the finger, nar- 



112 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



rowed the pelvic outlet so as not to admit a half crown. After trial with a 
crotchet, the cicatrix was divided, and delivery was speedily accomplished, 
but the patient died. — Ibid. 

Case LII. — iEtat. 28. The first labour was very tedious, and she had a 
narrow recovery. The head was detained at the perineum for two hours, 
without advancing, the pains being strong and frequent, by a strong callous 
band, across the vagina. This was divided, and she was delivered in a 
few minutes of a living child. The incision caused no pain, and but a 
drop or two of blood was lost. She recovered favourably. — Ibid. 

Case LIII. — Second child. She had been bled ^xii., for rigidity of the 
os, and heat of the os and vagina. Under strong pains, the head descended 
enveloped in the uterus, and on reaching the os externum was thrown to 
the right side by a firm cicatrix, resulting from laceration in a previous 
labour. After six more pains, there being no relaxation of the cicatrix, the 
head advancing, and the os thrown toward the sacrum, she was placed on 
her feet, and bled "upwards of two quarts," until she fainted. She was 
safely delivered by forceps, a half hour afterward, of a living child, and 
recovered rapidly. — Dewees' Midwifery. 

Case LIV. — When in labour sixteen hours, the pains being strong, the 
os externum scarcely admitting the finger, was close to the pubis, and dis- 
tended. A bridle ran from the pubis to the perineum, opposing the pas- 
sage of the head. Tobacco injections were twice tried, to no purpose. The 
bridle was then divided without apparent good. She was placed on her 
feet and bled, she became faint in the loss of ^x. of blood ; there was 
complete relaxation, and she was speedily delivered by forceps of a living 
child. Died on the sixth day, of cholera morbus. — Ibid. 

Case LV. — Second child. When twelve or fourteen hours in labour, the 
head distending the perineum, the os externum was no larger than a finger 
ring, and thrown close up to the pubis. A cicatrix ran down to the verge 
of the anus. Strong pains for several hours, produced no impression upon 
it. She was strong and healthy; the pulse now strong, frequent, and hard. 
She was bled to 5x1 with some benefit. She was then placed erect, and 
^xxv to ^xxx more taken. She fainted, and was soon delivered of a 
healthy child by forceps. She recovered well, and was delivered three 
years afterwards in the same way. — Ibid. 

Case LVI. — iEtat. 43. A circular contraction from a previous labour. 
It was not divided, " for fear of increased laceration on the passage of the 
head." Forceps were applied, and a living child delivered, "apparently 
without much injury to the vagina." — J. Bamsbotham's Midwifery, p. 
269. 

Case LVII. — The os externum was a small opening, scarcely admitting 
the finger, the contraction having been caused by inflammation, after te- 
dious labour. The head threatened to pass through the anus. When in 
labour about two days, the parts were divided in front and behind. The 
head was perforated, and she recovered well. — Ibid., p. 315. 

Case LVIII. — Second labour. The first was very protracted and instru- 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 113 



mental. A circular cicatrix at the upper part of the vagina yielded a little, 
but another of a gristly nature surrounded the os externum, barely admit- 
ting the finger. The pains though powerful, were fruitless. The stric- 
ture was divided, and a living child delivered by the long forceps. Re- 
covery was rapid and perfect. — Ingleby' s Obstet. Med., p. 115. 

Case LIX. — In her first labour she was delivered by forceps, and was 
supposed to have recovered. During pregnancy, the vagina was found to 
be nearly closed. At full term (Thursday night), after some hours, the os 
externum barely admitted the fore-finger, and within it, the vagina was 
closed by a membrane, which admitted only a probe. Through this fora- 
men the waters were dribbling. Active pains ensued, on Saturday morn- 
ing, the membrane was divided, and the arm felt in the vagina. The os 
externum was freely incised; much blood was lost, and she was delivered 
by version of a living child. She recovered well.' — Ibid. 

Case LX. — Was delivered by forceps, after a difficult labour ; a stricture 
was found far up the vagina. It gave way under strong pains, and de- 
livery was natural. — Ibid. 

Case LXI. — A healthy young woman. When labour had fairly set in, 
no os could be found, and the vagina was scarce two inches in depth. An 
opiate was given, and rest procured for some hours. An incision was then 
made toward the cervix, the os reached, and in two hours she was safely 
delivered. During childhood, the vagina had cohered above, leaving a pas- 
sage for the menses, which, after impregnation, closed up. — Br. Hamilton. 
See Guy's Hosp. Reps., vol. iv. p. 123. 

Case LXII.— (See case CLXII. of Cases of Rupture.) Firm bands ob- 
structed the vagina — delivery natural after three days — died. A rent w r as 
found in the vagina, opposite the sacral promontory. 

Case LXIII. — (See case CLXX. of same series.) A firm band obstructed 
the vagina — the bands were divided — rupture took place in the recto-vagi- 
nal septum, in an old cicatrix, four hours afterward.* 

Case LXIV. — iEtat. 28; robust; had had two children, the first still- 
born after severe labour, the second at the seventh month after an easy 
labour. Labour came on April 2d but went off entirely. It came on again 
on the 5th, at 2 A. M. On the 6th the womb ruptured, and she died on 
the 8th. 

Post-mortem. — The womb was ruptured in front, transversely, just above 
the vagina. Vagina almost completely closed by a septum a half inch 
thick, and of very firm texture, with a small orifice, through which a quill 

* For a case of -complete procidentia of the gravid uterus in parturition, treated by 
incision of the vagina, see Brit, and For. Med. Rev., vol. vi. p. 235, from Dr. Burdach, in 
Medicinische Zeitung, 1837. 

For a case of absence of external organs and delivery through an incision, in the 
direction of the vagina, see Lond. Lancet, 1827-8, vol. i. p. 385, from Arch. Gen., October 
1827. 

For another case of obstructed vagina, of which the result is not stated, see Arch. GSn., 
vol. xv. p. 268. 



114 Trask, Occlusion, etc. of the Os Uteri and Vagina. [July 



of small size might be forced. — Reported by Dr. Brainard, in Illinois 
Med. and Surg. Journ., May 1844. See Meigs' Translat. of Colombat. 

Case LXV. — iEtat. 16 years; had congenital narrowness of the vagina, 
which would not admit a goose-quill. After eleven years, she conceived, 
at the fifth month. The vagina began to dilate, and continued to do so 
till she was brought to bed and safely delivered. — Boyer, in Mems. de 
VAcad. des Sci., 1774, in Colombat, p. 99. 

Case LXVI. — Vagina so narrow as scarce to admit a quill. She became 
pregnant, and after three hours' labour gave birth to a large healthy child, 
The vagina dilated in one night. — Ibid. 

Case LXVII. — Vagina found narrow, so as scarce to admit a quill. She 
was safely delivered. — From Brazilian Med. Rev. , in Lancette Francaise, 
Gaz. des Hopitaux, in Colombat, p. 99. 

Case LXVIII. — iEtat. 35, fourth confinement ; full time. Called at 4 
P. M. Waters escaped on the previous morning, and the pains commenced 
an hour after. Had procidentia uteri for a year, two or three inches being 
external. Cervix two or three inches without the vulva ; firm, corrugated, 
and dry. At 4 A. M. next day, forceps applied, but the procidentia greatly 
increasing, were withdrawn, the tumour being eight inches long, and five 
in diameter. Soon after made an incision one and a half inches, and in- 
creased it one inch. Parts rent one and a half inches farther ; child born 
alive ; hemorrhage slight ; substance of the cervix cartilaginous. Reco- 
vered. — Amer. Jour. Med. Sci., Oct. 1846, Dr. A. K. Gardner. 

Severe labour was the cause of most of the instances of contracted and 
obliterated vagina. It is distinctly stated in Cases XLII., XLV., XLVI., 
XLVIII., XLIX., L., LI., LIL, LIIL, LVL, LVIL, LVIIL, LIX., LX., 
LXIV., while it was probably the cause in some others. In Case XL VII. 
it arose from attempts to procure abortion ; in Case LXI. from vaginitis 
during childhood ; Case XLIV. was also a primipara; and, in Case LXV., 
the narrowness was congenital. In Arch. Gen., vol. xviii. p. 471, Lisfranc 
reports a case of complete occlusion of the vagina, from neglected venereal 
ulcers. 

Of those in which there was no active interference, in Cases XLIV. and 
LX. the obstructing bands were rent by force of the pains; in Cases LXV., 
LXVI., LXVII., the vagina dilated; and, in Case LVL, the patient was 
delivered by forceps. These all recovered. Cases L., LI., LIV., LV., 
yielded to venesection. Cases XLVIL, LXII., LXIV., were let alone, and 
they died, as also Case XLVIL, in which some attempt had been made to 
open the passage, but unsuccessfully, and rupture of the womb ensued. 
So that of the eight cases abandoned to nature, three were fatal. 

Cases XLII., XLV., XLVI., XLVIII., XLIX., LI., LIL, LVIL, LVIIL, 
LIX., LXI., in all twelve, recovered after incision of the obstructing mem- 
branes and tissues. Case LXIII. is the only instance of death after a 



1848.] Trask, Occlusion, etc. of the Os Uteri and Vagina. 115 

division of the obstacle, and in this case the rupture that caused the death 
occurred in an old cicatrix. The four cases attended by rupture of the 
uterus or vagina, show that that fearful accident is to be seriously appre- 
hended when the impediment to delivery is allowed to continue. 

If rupture of the womb is to be feared under the action of ordinary con- 
tractions, it certainly follows that the administration of ergot, with a view 
to overcome the obstacle by increased violence of the pains, is to be care- 
fully avoided as hazardous in the extreme. 

We have seen that in every instance but one, in which the stricture was 
divided, the woman recovered, while in several in which it was neglected, 
rupture of the womb or fatal exhaustion followed. Cases LXIV., LXV., 
LXVI., are remarkable exceptions, inasmuch as extreme contraction disap- 
peared during labour and the delivery was natural. They show us what 
may, by possibility, happen ; and yet the history of the other cases indi- 
cates that these are exceptions to a general rule. 

Our cases show that while abandonment to nature is attended by great 
risks, division of the stricture by the knife is almost perfectly safe. Cer- 
tain it is, that when the patient has been suffering during hours of agony, 
without any advance of the head, the artificial division, or spontaneous 
laceration of the opposing bands or cicatrices, has permitted almost imme- 
diate delivery. 

Dewees recommends large abstractions of blood, and relates three in- 
stances in which it apparently proved successful. Hamilton also relates 
one, in which he practised the same. A truly formidable depletion was 
required in one at least, of Dewees', such as could not fail to peril the 
safety of almost any woman. We know of no other author who has re- 
commended blood-letting to a similar extent. 

The general safety of incisions, with the risk of dangerous laceration if 
left alone, must certainly encourage an early resort to the operation. It 
involves no important organs, is easy of performance, is attended by little 
pain, and almost always by only a trifling degree of hemorrhage, and is to 
be performed upon parts that must probably undergo spontaneous lacera- 
tion before labour is completed. • 

These considerations point to the propriety of dividing the opposing 
structures, after a fair trial of relaxants, and before the powers of life have 
begun to yield from exhaustion, or the soft parts to suffer from long-con- 
tinued pressure. 

Dr. Ingleby advises that the incisions should be made during a pain. 
During convalescence, after a division of the stricture, the parts have a 
tendency to reunite, and this should be guarded against by appropriate 
management. So great is the risk of partial obliteration of the vagina from 
inflammation after severe labour, that Dr. Ingleby recommends an examina- 
tion of the vagina in all instances of really difficult labour, within a month 
after delivery. 



116 



Warren, Operation for Artificial Anus. 



[July 



Art. IX. — Operation for Artificial Anus. By J. Mason Warren, M. D., 
one of the Surgeons to the Massachusetts Gen. Hospital. 

Artificial anus is an affection generally caused by the sloughing of the 
intestine in strangulated hernia, although occasionally, the result of abscess 
and penetrating wounds. Sometimes a small portion only of the calibre of 
the intestine is destroyed, the bowel becomes attached to the parietes of the 
abdomen, and a fistulous opening is the result, usually amenable to the 
ordinary method of treatment. At other times a whole loop of the bowel 
sloughs off, and both ends of the intestine unite to the abdominal walls, 
leaving an opening from which the feces are constantly discharged, and 
only to be remedied by surgical means. 

Cases of the latter character are of unusual occurrence, and the means 
for their strictly scientific treatment by surgical operation, have not, until 
within a few years, been fully established. The one I intend to relate is, I 
believe, the only instance successfully operated upon after the method of 
Dupuytren, in this part of the country, so far, at least, as my medical ex- 
perience extends. 

A patient with this affliction is one that may fully claim the sympathies 
of those called upon to administer to, and alleviate human suffering. 
Generally suspended, in the full possession of his mental faculties, between 
life and death, he is destined, unless relieved, to drag out a miserable ex- 
istence, an object of disgust to himself and a burden to his friends, or to 
sink worn out by pain, and the emaciation produced by deficient nutrition. 
Great satisfaction must therefore be felt by the surgeon, if he can be the 
means of relieving so distressing a misfortune. 

The patient with artificial anus, of whose case I propose to give an ac- 
count, was sent to me by Dr. Brown, of Nova Scotia, in June, 1847. She 
was thirty-four years old, the mother of six children, and previous to the 
occurrence of the present accident, of good constitution. A small crural 
hernia had existed on the right side for an indefinite period of time. 

Dr. Brown was called to her fourteen months previously, and found her 
labouring under a strangulated hernia of forty-eight hours' duration. An 
operation was immediately performed, but on opening the sac, the intestine 
was exposed in a gangrenous state. The stricture was therefore divided, 
and the intestine left in the wound. At the end of a week the sphacelated 
portion separated, and the feces flowed freely through the opening. After 
some time she partially regained her health, was able to sit up, and finally 
to work moderately, until the following September, when abscesses began 
to form in different parts of the thigh. From this period she gradually lost 
her flesh, and declined in strength. Two of the abscesses were opened by 
the lancet; the others, on the under surface of the limb, opened and dis- 
charged spontaneously. Pus at first issued, followed by fecal matter, and 
great suffering attended the effusion of the latter into the soft parts. Until 
within a few weeks previous to her coming under my care, there were oc- 



1848.] 



Warren, Operation for Artificial Anus. 



117 



casional fecal discharges per anum, but the greater proportion of matter 
was evacuated through the various fistulous openings. 

The patient arrived in town in the early part of June, 1847, just after 
my term of service had expired at the hospital, but through the politeness 
of Dr. Townsend, who was then in attendance at that institution, she was 
placed under my charge. Her condition at that time was as follows: 

She was extremely weak and emaciated ; the countenance pale, nearly 
exsanguineous, indicating the almost total failure of the assimilating pro- 
cess. From long confinement she had become nervous and timorous, 
hardly allowing the slightest examination. And on the day subsequent to 
her entrance, she was so completely homesick, that notwithstanding the 
great trouble and expense undergone by her physician and friends to enable 
her to accomplish her journey to Boston, she insisted on returning home at 
once by the same vessel in which she came. After a day or two of con- 
sideration, however, and by a little persuasion, she was induced to change 
her mind on this point. 

The position of the patient was almost entirely on her back. The feces 
in a very liquid state were constantly running out through two openings in the 
groin and three in the posterior part of the thigh. The right limb was 
drawn up almost to a right angle with the body, and the whole thigh much 
enlarged and hardened. The skin around the openings in the groin, had a 
red irritated look, was thickened almost to callosity, and excoriated. The 
openings were quite small, so as hardly to admit an instrument larger than 
a common director. 

A nourishing diet was allowed and great cleanliness of the wounds en- 
joined, with the more especial object of preventing the painful excoriations. 

The situation of the intestine could not at first be determined, which 
added to the embarrassment of the case. In those of a similar nature, 
which I had an opportunity of seeing abroad under the care of Dupuytren, 
the intestine opened on the surface of the abdomen by a large aperture, and 
there was no difficulty in exploring at once, the ends of the bowel with the 
finger, or by instruments. In the present instance the fistulous openings 
ran in every direction ; those in the groin were immediately in the neigh- 
bourhood of the probable orifice of the artificial anus, allowing a probe to 
penetrate for its entire length. 

I therefore determined to dilate the two latter openings, which was done 
very gradually by sponge-tents, on account of the sensitiveness of the pa- 
tient to any manipulations, and it required the persevering application of 
this method for a month, before the two ends of the intestine could be with 
certainty distinguished. This, however, was finally accomplished, and a 
gum-elastic bougie passed into the upper and another into the lower orifices 
of the intestine. The bougie first penetrated through a thick callous mass 
of integument, then through the muscular or tendinous covering of the ab- 
domen, in all about an inch in depth, when the septum or spur, as it has 
been called, which separates the two ends, was encountered and with dif- 
ficulty entered, being so closely applied to the parietes of the abdomen as 
to prevent the least passage of matter from the upper into the lower part of 
the bowel. There had not been in fact, for two months, the slightest fecal 
discharge per anum. The intestinal ends seemed to lie parallel to each 
other, so that the bougies introduced for exploring made but a very slight 
angle. The patient still remained nervous and quite feeble. 

I directed that the sponge-tents should be continued; also that a pint of 
oatmeal gruel should be given, per anum, daily, for the purpose, both of 



118 



Warren, Operation for Artificial Anus. 



[July 



stimulating the intestinal coats to the performance of their natural functions, 
and with the object of enlarging the calibre of the bowel, which must have 
become much contracted from long disease. 

On the following day I found that some scybalae had come away with 
the enema; and, on the next day, the injected fluid made its appearance at 
the apertures in the groin. 

In the course of a few days the principal opening had become so dilated, 
that by a steady and patiently applied force, I could insinuate the little 
finger quite down to the intestine. The septum could now be distinctly 
felt lying against the wall of the abdomen, and be hooked up, so as to per- 
mit the end of the finger to be carried into the lower portion. The sensa- 
tion of the valve was that of a delicate membrane, like the coronary valves 
of the aorta, though somewhat more resisting. A director was now carried 
down at the side of the finger for the purpose of keeping the valve open, a 
gum-elastic catheter passed in, and a quantity of warm water injected, to 
make sure that the lower orifice had been found. This water afterwards 
appeared, and was discharged per vias naturales. 

The patient being well prepared, I determined to apply the enterotome, 
which was done July 12th. Having made sure of the lower opening by a 
director, as on the day previous, the male branch of Dupuytren's entero- 
tome was carried into the lower intestine; the director was then withdrawn, 
and the female branch introduced with ease into the upper. The two 
parts of the instrument now occupied nearly the whole calibre of the dilated 
passage leading to the gut. It was necessary particularly to separate and 
lock them. This I found at once to be impossible, for the jaws of the 
female portion would not allow of sufficient motion at the hinge to lock with 
the other part of the instrument. If the intestine had opened directly on 
the abdominal surface, there would have been no difficulty, but the locking 
of the forceps under the existing circumstances was impracticable. 

I therefore withdrew the instrument, and had recourse to another, which 
has since proved much better than the enterotome of Dupuytren. This 
instrument was about six inches in length; the handle was constructed with 
a screw-vice, and the joint with a movable pivot, as in that of Dupuytren: 
the blades, however, were different. In the place of one blade being re- 
ceived into a groove in the other, they were serrated, like the polypus for- 
ceps, for the space^of three inches. The whole instrument was four inches 
and a half long, or about two inches shorter than that of Dupuytren. The 
blades being introduced in the manner already described were locked with- 
out difficulty, and at once brought together as tightly as the screw would 
permit. 

On the next day I found her quite free from pain. She had complained 
a little for a few hours after the instrument had been put in place, but there 
was a question whether this might not have arisen from fear. 

The fecal matters passed by the side of the instrument, and warm water 
was daily injected into the wound, to prevent any obstruction. She had 
also an enema daily, which kept the lower bowel in action. 

On July 15th, three days after its application, the instrument came away. 
In the jaws of the forceps, and bearing the impress of the teeth, was a 
blackish slough, two inches and a half long, four lines wide, and about 
three thick. The finger, passed into the orifice, could distinguish an open- 
ing between the two ends of the intestine, corresponding in size to the 
slough, the edges of which were greatly thickened and fleshy, imparting a 
sensation entirely unlike the delicate valvular one of a few days previous. 



1848.] Warren, Operation for Artificial Anus. 119 



This examination was conducted with the greatest delicacy, from fear of 
destroying the adhesions, which must have been, of course, at this early 
period, of the slightest kind. 

In the afternoon she had a small fecal discharge through the wound. 
She complained of no pain, and there was no tenderness of the abdomen. 

On the following day, the 16th, she was quite comfortable, had had a free 
dejection per anum from an enema, more slimy in its character than usual. 
There had been no discharge from the wound since the day before. A 
gentle compression was made by means of a compress and bandage on the 
openings in the groin, and the orifices ordered to be touched daily with the 
nitrate of silver. 

The patient improved in health, rapidly acquired her strength, and there 
was no farther discharge at the artificial anus from the day of the separa- 
tion of the instrument until she left the hospital, at which time the open- 
ings in the groin had almost completely cicatrized. 

On July 29th, being very eager to return home, she was discharged 
from the institution at her own request, but against my wishes, as I was 
anxious to watch the progress of the case to its very close. 

From a desire to learn the final result of this case, I have lately ad- 
dressed a letter to Dr. Brown, of Horton, N. S., her physician, and re- 
ceived a reply bearing date May 5th, 1848. In his answer this gentle- 
man informed me, that immediately upon her return my patient was 
greatly improved both in health and spirits, the feces had their natural 
exit, and everything looked very promising. In a short time, however, 
owing to over-indulgence in the use of coarse, flatulent food, and the want 
of that general surveillance so necessary for this class of patients, fecal 
matters had again appeared at the old orifice, as well as at several places 
on the hip, some of which were fresh outlets. This was the condition of 
things in December, when Dr. B. was summoned to a meeting of the 
legislature at Halifax. 

"On my return in April," writes this gentleman, " about a week ago, I 
was quite taken by surprise to find our patient perfectly recovered, looking 
as plump and gay as ever, and busily employed about her house. Being 
in haste, and she being busy, I did not examine her, but she informed me, 
that all the ulcers as well as the original outlet were entirely healed, ex- 
cept one new one, and that had not discharged fecal matters for sometime, 
and was in fact, nearly healed ; that the hip had greatly decreased in size, 
and had assumed quite a natural appearance ; that her bowels were en- 
tirely regular, and she could take any kind of food without the least incon- 
venience. She even said, she had not enjoyed so good general health for 
several years previous to her misfortune, as now." 

On reviewing the above case it will be perceived, that it presented dif- 
ficulties of a formidable character. In the first place the extreme debility 
and emaciation of the patient, and her great mental depression were ob- 
stacles almost as troublesome to contend with, as the disease itself. Twice 
after much labour had been expended, and some progress made in the pre- 
liminary treatment, she insisted on relinquishing it at once and returning 
home ; and on the day when the instrument was to be applied, she declared 
that she was certain she must die the following night, and that it was quite 
useless to attempt the operation. These depressed turns generally passed 
off after a time, and then the patient was very urgent to have the treatment 



120 Warren, Operation for Artificial Anus. [July 



continued, but for the moment they were sufficiently discouraging to the 
surgeon. 

The numerous fistulous openings, with the effusion of fecal matter into 
the groin and back part of the thigh, occasioned considerable embarrass- 
ment in pursuing the treatment for discovering the end of the intestine. 
Added to this, and caused by it, the thighs were flexed nearly to a right 
angle with the body, and were constantly in the way of the instruments 
used for exploring the artificial openings. 

The instrument used, I conceive to possess great advantages over that 
of Dupuytren. In fact, it consisted of, or may be almost exactly repre- 
sented by a common pair of old-fashioned polypus forceps, with the branches 
detached and united by a movable pivot, instead of a fixed joint, the han- 
dles perforated with a screw-vice, and the jaws serrated throughout. It is 
less clumsy than that of Dupuytren, causes more complete strangulation, 
and does its work in less than half the time.* By an examination of the 
cases of this distinguished French surgeon, it will be found, that the entero- 
tome generally separated about the seventh or eighth day : in the present 
instance it came away on the third, yet no effusion or other evil conse- 
quence resulted, although the patient was as little provided with the mate- 
rials for forming plastic lymph as can well be imagined. She was in fact, 
almost exsanguineous. 

In the relation of this case we have only mentioned the course of treat- 
ment ordinarily pursued by Dupuytren, without alluding to the methods of 
Physick, Gross, and others in this country, or in Europe, who have done 
so much to advance this branch of surgery. 

A case of a similar kind to that narrated, occurred to me in an infant 
some years since, and, as it illustrates one of the accidents liable to take 
place at any moment in patients labouring under this unfortunate affection, 
namely, a prolapse of the ends of the bowel, the details may be here given. 

I was requested by the medical attendant of the family to see an infant 
eight months old, and received the following history from him. He was 
first called to it when three weeks old : the parents stated to him, that for a 
few days subsequent to its birth it was in much distress, and had no alvine 
evacuation until the cord separated, when an exudation took place at the 
navel, followed by much relief. Shortly after, a small red tumour appeared 
at this spot, from the central portion of which the fecal evacuations oc- 
curred ; there was no discharge peranum. He directed them to make use 
of a compress and bandage over the tumour, and under this treatment the 
child began to have evacuations by the anus, to gain strength and flesh. I 
advised that this treatment should be persevered in. 

About two months subsequently, after a sudden exertion, a couple of 
tumours protruded from the navel, attended with some constitutional symp- 
toms, and an entire stoppage of the evacuations. I saw the patient two 
days afterwards, and at once recognized a prolapsus of both ends of the 
intestine. The tumours lay across the abdomen, one to the right side, the 

* I am not aware of the name of the inventor of this instrument, or whether it was 
constructed for the purpose for which it was employed in the former cases. 



1848.] 



Bissel on Poisoning by Arsenic. 



121 



other to the left; one portion, which, proved to be the lower, was dark- 
coloured, and more contracted than the other. The second, or upper part 
of the bowel, was larger, covered with mucus, and the vermicular motion 
could be distinctly seen in it. An effort had already been made to reduce 
them into the abdomen, but without effect; and a proposition had been 
made by some physician who had seen the case to apply a ligature to the 
root. This was done in doubt as to the exact nature of the affection ; and, 
in fact, the parts were so changed, that they were with difficulty distin- 
guished as belonging to the intestinal canal. 

The child being cold, its pulse small, and having every appearance of 
rapidly sinking, I declined for the moment any operation, but advised sti- 
mulants, and agreed, if it revived, to attempt an operation on the following 
day for the purpose of returning the bowel. 

On the next morning, the child having revived under the treatment sug- 
gested, the following operation was practised. A small neck or tunnel 
existed at the navel where the intestine protruded, being, in fact, the com- 
mon everted orifice for the two openings of the bowel. An incision was 
made at this spot, being within the peritoneum, though protruded from the 
abdominal cavity. The two ends of the intestine as they issued, were now 
seized with a blunt hook, and slight traction made on them. The inverted 
portion gradually began to recede, and by continuing this manoeuvre, at the 
same time using some external pressure on the tumour, it gradually re- 
turned into the interior of the abdomen. The neck of the tumgur, where 
the incision was made, and which represented the tunnel shaped portion, 
was retained outside, so as to prevent the effusion of fecal matters through 
it into the peritoneum. Immediately on the return of the bowel, free 
evacuations took place from the anus, with great apparent relief. The pa- 
tient, however, did not rally, but sunk, and died on the next day. 

An examination after death presented no peritoneal inflammation, or 
effusion, and no attempt seemed to have been made by nature to close the 
incision of the operation, showing the low state of the vital powers at the 
time it was done. The upper portion, which had been returned, looked 
comparatively healthy: the lower was quite dark coloured, and showed the 
effects of the partial strangulation ; an invagination of its coats for about an 
inch also was discerned. 

Boston, May 30th, 1848. 



Art. X. — Poisoning by Arsenic Successfully Treated ivith Calcined 
Magnesia. By Emory Bissel, M. D., of Nor walk, Conn. 

Peter Galpin, a labourer, aged 27, a powerful and robust young man, of 
intemperate habits, attempted suicide on the evening of the 4th of March 
last, by taking arsenic. As is often the fact, he was prompted to the deed 
by those horrors and remorse of conscience which so often succeed a de- 
bauch. The quantity taken, as nearly as could be determined, was not far 
from a scruple. When I was first apprised of the fact, two hours had 
elapsed from the time it was taken. I hastened the messenger who came 
for me as quickly back as possible, with some thirty grains of sulphate of 
zinc — in two doses — with directions to administer it as soon as he could 



122 



Bissel on Poisoning by Arsenic. 



[July 



reach home, on horseback — distant about one mile — to give the second 
parcel in ten minutes, if needful. I followed as expeditiously as I could; 
when I arrived he had vomited freely twice, but without any relief. The 
family had given him copious draughts of a weak infusion of tobacco, which 
produced no other effect than to increase his sufferings, which at this time 
were extreme; so much so, that he begged me to kill him at once, if I could 
not end his pain in any other way. His pulse was one hundred and thirty 
per minute, small and wiry. He complained of great constriction and dry- 
ness of the fauces, but chiefly of a most agonizing pain and burning in the 
stomach; it seeming, as he expressed it, "as if it were filled with burning 
coals." As nearly three hours had now elapsed, since the poison entered 
the stomach, 1 considered that any further effort to evacuate it would be 
futile, and that if life was saved at all, it must be by the antidotal power of 
some medicinal agent. Having had my attention directed to the experi- 
ments of Prof. Peter, of Transylvania University, and the case of Le- 
page, published in the January and April numbers of this Journal, in 1847, 
I determined to give the calcined magnesia a fair trial, and accordingly put 
it up in drachm doses, to be given every hour mixed in milk and water. 
During the hour which I remained with him, his symptoms were rapidly 
becoming more unfavourable. The pulse was one hundred and fifty per 
minute, the constriction and dryness of the fauces extreme, the whole sur- 
face bedewed with perspiration, the pain and burning sensation in the 
stomach seemed augmented to the highest possible degree, whilst the right 
hand was entirely paralyzed; in short, everything betokened a speedy dis- 
solution. I left him at 10 o'clock, in charge of the mistress of the family, 
whom I knew to be an intelligent and faithful nurse. On visiting him the 
next morning, instead of finding him dead, as I much feared, 1 was most 
happily surprised to find him very quietly dozing in an easy chair. I 
learned from the lady, who had been unremitting in her care of him during 
the whole night, that in a very few minutes (not more than five or ten), 
after taking the first dose of magnesia, he said he felt much relieved, and 
before the time came for the second dose, he had fallen into a doze. She 
stated that each successive dose had produced the most surprising and 
marked mitigation of every symptom, and that long before morning he was 
entirely freed from suffering, and had, on the whole, passed a quiet and 
comfortable night. The bowels had moved freely and easily twice during 
the time. He complained of nothing save a general weakness, and a sort 
of faintness at the pit of the stomach. The right hand had recovered its 
power, and the pulse had fallen to eighty-five per minute. Directed to 
continue the magnesia, through the day, once in four hours, and to give 
light nourishment. On the sixth I made my third and last visit, as the 
young man seemed to require nothing but nursing, and a little time, for the 
recovery of his strength. I have since learned, that in a very few days he 
resumed his labour upon the farm, and felt no inconvenience from what he 
had taken, except a muscular weakness of the lower extremities, which 
was not very great. The case, in some of its aspects, much resembles that 
of Lepage, especially in the prompt and efficacious effects of the remedy, 
and the speedy recovery which followed. Should future cases yield re- 
sults as gratifying as these two, we may indeed congratulate the profession 
in the possession of a sovereign and prompt antidote, always at hand and 
easily administered, to the dreadful poison by which such numbers of our 
race have found a terrific and agonizing death. 
Norwalk, April 14th, 1848. 



1848.] 



123 



REVIEW. 

Art. XI. — Practical Observations on Midwifery, and the Diseases inci- 
dent to the Puerperal State. By Alfred H. McClintock, M. D., 
F.R.C.S. I., Ex-assistant of the Dublin Lying-in Hospital; Vice-Presi- 
dent of the Dublin Obstetric Society; and Lecturer on Midwifery and 
the Diseases of Women and Children in the School of Medicine, Park 
St.: and Samuel L. Hardy, M. D., F.R.C. S.I. , Ex-assistant of the 
Dublin Lying-in Hospital, and Vice-president of the Dublin Obstetric 
Society. " Multurn restat adhuc operis, multumque restabit; nec ulli 
nato post mille saecula praecludetur occasio aliquid adhuc adjiciendi." — 
Seneca. Dublin, 1848: 8vo., pp. 368. 

The present work is neither a system of midwifery, nor a systematic 
treatise upon the pathology and therapeutics of the puerperal state; it is 
one of even greater value and deeper interest to the practitioner of obste- 
trics, who will not fail to derive from the very excellent observations it con- 
tains upon the different subjects relating to the treatment of parturition and 
puerperal diseases, a large amount of practical information. It is, in fact, a 
careful exposition of the results of the practice of the Dublin Lying-in 
Hospital during the three years from January 1st, 1842, to January 1st, 
1845; embracing a period when, under the care of one of the most expe- 
rienced masters of the institution, Dr. Johnson, six thousand six hundred 
and thirty-four women were delivered in its wards. 

It comprises numerous, very comprehensive, and well-arranged clinical 
and statistical tables, presenting almost every particular of importance con- 
nected with the statistics of the natural, tedious, difficult, preternatural and 
complex labours, twin births and funis presentations, and of the cases of 
convulsions and rupture of the uterus, which occurred in the institution 
during the above period. These several tables are useful as well as inte- 
resting; and we have the assurance of the authors that the fullest reliance 
may be placed on their accuracy. 

The chief value of the work, however, consists in its practical observa- 
tions upon the management of the different forms of labour, and upon 
the nature and treatment of the accidents of parturition, and of the more 
prominent of the puerperal diseases. In the preparation of this portion 
of the work, the authors state, that their main, they might almost say, 
their exclusive object has been to be as practical as possible, avoiding all 
speculative or unprofitable questions, and estimating the importance of each 
subject solely by its claims on our attention, and the interest it possesses at 
the bedside of the patient. 

The strictly clinical character of these observations, the very favourable 
circumstances under which they were made, and the ample means afforded 
to the authors for testing their accuracy, press them strongly upon our 
notice. Valuable as is unquestionably the results of that experience which 
is derived from private practice, they can bear no comparison to those 
afforded by the practice of large and well-conducted public hospitals. 
This is true in all the departments of practical medicine and surgery, and 



124 



Review. 



[July 



in none more so, than in that of obstetrics. The profession owe much to 
the gentlemen having charge of such institutions, who, while they have 
faithfully improved the opportunities which their situations present to them, 
have not withheld from their professional brethren, whose field for obser- 
vation is more restricted, the result of their labours. 

It has been already stated, that the report of the Dublin Lying-in Hospi- 
tal, embodied in the volume before us, comprises a period, during which 
6634 females were delivered in the institution. These women gave birth to 
6702 children. The number of first labours was 2125, or nearly one-third. 

The total number of deaths that took place, within the period specified, 
was 65, or one in every 102 cases. Thirty-five of these deaths occurred 
among the primi parse. In eleven of the fatal cases, the causes of death 
were diseases altogether independent of the puerperal state, and in four 
others, the patients were, at the time of their admission, in a dying state. 
If these fifteen cases be deducted, the average mortality will be reduced to 
1 in 132. 

The total number of children, exclusive of abortions, which the 6634 
women delivered in the hospital gave birth to, is stated to be 20,680 ; 
viz., 11,032 boys and 9,648 girls. The total number of males born in the 
hospital, during the period embraced in the report, was 3551, of whom 198 
were born dead, and 62 in a putrid state ; the total number of females 
amounted to 3151, of whom 127 were born dead, and 80 in a putrid state. Of 
the entire number of children, 108 were premature ; viz., 52 boys, of whom 
9 were dead born, and 15 in a putrid state, — and 56 girls, of whom 9 were 
dead born, and 22 in a putrid state. 

u An interesting, and at the same time, a practical question here arises; viz., 
£ What influence the premature death of the child has upon the duration of preg- 
nancy]' The most satisfactory way by which we can solve this question, is to 
ascertain, in cases of putrid births, the probable time at which the foetus ceased to 
live. Where this is done, it will be very generally found, on close inquiry, that 
about ten days or a fortnight have elapsed since the period at which the rigor an- 
nouncing the child's death took place; or, in the absence of this indicative sign, 
since the mother last felt the foetal movements. A knowledge of this singular fact, 
first remarked to us by Dr. Johnson, and which, with a few exceptions, fully 
accords with our own experience, will ofien prove of considerable value to the 
practitioner in cases of the premature death of the fcctus, by enabling him to qua- 
lify his prognosis, and to give such directions for the patient's guidance as the 
circumstance of a near approaching confinement ought to suggest." 

In the case of twins, the authors remark, where one becomes blighted, it 
would seem as if Nature waived the law, just referred to, out of considera- 
tion for the living foetus, and that, therefore, gestation in these cases pro- 
ceeds undisturbed to the full period. 

"There is another point connected with premature births, which possess some 
interest, and is deserving of attention ; viz., that amongst them there occurs a 
much greater proportion of preternatural presentations — more especially of the 
lower extremities, — than takes place at the full term of pregnancy. Thus of the 
108 premature children, above mentioned, 17 presented with the breech, 12 pre- 
sented footling, and 9 with the arm, making, in all, 38, thereby giving a propor- 
tion of one out of every three cases nearly : whereas, at the full term of ge.-tation, 
the frequency of preternatural presentations is only about one in thirty, between 
which and the former there is a vast difference." 

Under the head of natural labour, we are presented with some excellent 
remarks upon the use and management of the binder, and the mode of 
supporting the perinaeum. The binder is directed to be applied imme- 
diately upon the birth of the child. The authors consider that it can 



1848.] 



Practical Observations on Midwifery. 



125 



scarcely be questioned that a proper attention to the application, and the 
judicious management; of the bmder, promote the favourable separation 
of the placenta. In confirmation of this, they state that, in one instance 
only, throughout the period comprised in their report, and for two years 
previously, had the hand to be passed into the uterus for the removal of a 
placenta retained from hour-glass contraction; and in a very limited num- 
ber of cases was it required in consequence of inaction. 

The importance of the early and proper application of the binder, imme- 
diately upon the termination of every case of labour, is fully recognized by 
tne leading obstetricians of this country, and strongly enforced in the writ- 
ings and lectures of our writers on and teachers of midwifery ; it cannot, 
however, be too frequently urged upon the young practitioner. It is not 
merely from the early application of the binder, however, that much good 
is to be obtained and not a little evil avoided, but equally from its proper 
adjustment. The practitioner would do well to adjust it himself in every 
instance ; from the manner in which we have seen it put on by the gene- 
rality of nurses, it is calculated to do but little good, if it be not, in some 
cases, productive of positive injury. 

In guarding the perinseum, the injurious consequences of an error into 
which junior practitioners are apt to fall, in commencing its support too 
soon, are pointed out. By this procedure it is made dry and hot, and liable 
to become inflamed and rigid. The dilatation of the soft parts is not a 
merely mechanical, but a purely vital process ; consequently, anything 
which tends to alter or derange the natural and healthy condition of these 
parts, will indispose them for expanding before the descending head of the 
child. Hence, it should be a main object to keep the perinseum as free 
as possible from all irritation, and for this reason, the authors advise that 
we should abstain from giving any support until the increasing thinness of 
the part, and the extreme tension of the fourchette, indicate that delivery is 
near at hand. 

The whole of the authors' observations on this subject are highly judi- 
cious. A rupture of the perinseum is always a very serious accident, and 
the most distressing consequences may ensue even upon lacerations that 
do not involve either the rectum or its sphincters. 

"Amongst the humble and working classes," our authors remark, "this acci- 
dent is very apt to entail incurable prolapse of the uterus or bladder; for, when 
the support of the perinseum is gone, the chance of permanently restoring the dis- 
placed organ to its natural situation is small indeed, and the palliative measure of 
wearing a pessary is almost impracticable." 

The importance of unremitting watchfulness during the ordinary conva- 
lescence from natural labour, in order to secure the patient's safe recovery, 
is very ably enforced. The circumstance of castor oil, the purgative gene- 
rally administered within a day or two after labour, being ill-suited for pa- 
tients who have hemorrhoids, as it is very apt in such to produce tenesmus, 
and considerable irritation of the rectum, must be familiar to every practi- 
tioner. There are some females, also, who have an unconquerable aver- 
sion to this medicine, and if prevailed on to swallow a dose, the stomach 
immediately rejects it. In both cases, we are assured that the following 
prescription of Dr. Johnson will be found to answer admirably well. — — 
Sulph. magnesiae ^ss; carb. magnesise Jss; infusi sennse 5iss; tinct. sen- 
noe £ss; mannse opt. 3iij ; aqua cinnamomi ^ij. M. A wineglass for a dose. 

"An observation,' 5 the authors remark, " has been made by the late Dr. Joseph 
Clarke {Trans, of the Assoc. of the Coll. of Phys., Dublin, vol. i. 371), to the effect 
No. XXXL_July, 1848. 9 



126 



Review. 



[July 



that those females who suffer much from after-pains, usually have painful men- 
struation. This is a curious coincidence, the truth of which we have frequently 
verified, and we would extend its application to those cases where they occur 
with first children. In these instances, which are rare, it is most necessary to 
keep a vigilant eye over the patient, and to. view the after-pains with much sus- 
picion, as they are very apt to turn into actual inflammation, or, perhaps, to speak 
more correctly, to be induced by inflammation." 

On three or four occasions, the authors have known cramps in the legs 
to have evidently taken the place of after-pains, and, in fact, to have com- 
pletely supplanted them. These cramps came on soon after labour, and 
continued for some hours, during which period, and subsequently, the 
female was entirely free from all uterine pain, although she had suffered 
from after-pains in her previous confinement; at the same time, the dis- 
charge of coagulafrom the uterus showed that there existed adequate cause 
for the production of after-pains, while the cramps were materially less- 
ened or removed by the same treatment that is ordinarily successful in 
suspending after-pains. 

When there exists a disposition to sore nipples, or where the female has 
suffered from this cause after her previous confinements, the authors advise 
that the infant be withheld from the breast till after the secretion of the 
milk, and " untilthe breast has become 1 free,' as it is appropriately termed." 
They also consider it objectionable to let the child draw the breasts whilst 
they are distended and painful from the first secretion of the milk, and 
when as yet it does not flow freely through the lactiferous tubes; from the 
frequent ineffectual attempts of the child to procure nourishment, excoriation 
of the nipple is liable to be produced, and this, in its turn, endangers in- 
flammation of the gland. The tumid and painful state of the mammae is, 
according to their experience, best relieved by frictions with warm oil, and 
if any febrile excitement attend — as is not uncommon — small and frequently 
repeated doses of tartar emetic, w 7 ith some mild purgative. If, after friction 
of the breasts, they continue hard and tense, benefit is derived from keeping 
them enveloped in a piece of soft linen spread with a cerate composed of 
wax and olive oil, melted together, and having in the centre a hole cut for 
the nipple. This acts like a perpetual stupe, and keeps the breasts soft 
and relaxed. 

They feel persuaded that by attention to the above simple rules, many- 
cases of mammary abscess may be prevented, in confirmation of which they 
mention that only two cases of suppuration of the breast occurred in the 
hospital during the three years of their report, and that Dr. Johnson, in his 
private practice, has always pursued the same plan with like success. 

When there is reason to dread an inflammation of the breast, the child is 
entirely withheld from it, and the affected gland is kept soft by friction ; if 
the nipple itself appears to be the seat of any inflammation, a bread and 
milk poultice is applied to it. 

Among the various topical applications for sore nipples employed in the 
hospital, the tincture of catechu holds a high place; it is best adapted for 
the simply excoriated or abraded nipple; nearly similar to this, but more 
cleanly, is the solution of pure tannin, made by dissolving five grains in an 
ounce of distilled water. The following is a favourite lotion with Dr. John- 
son, who has been in the habit of using it for many years. — R. — Sub. bo- 
rat, sodas 3ij; cretae precipitat. ^i; spiritus vini, aquae rosas, aa §iij. M. 
This may be applied alternately with the following ointment, or the latter 
may be used alone. R. — Ceras albas Jivss ; 1. amygdal. dulc. ^i; mellrs 
despumat. ^ss. Dissolve fully by means of heat, and then gradually add 



1848.] 



Practical Observations on Midwifery. 



127 



bals. Peruviawi 3iiss. M. In some cases, benefit has been known to result 
from the use of tincture of galls and compound tincture of benzoin, in equal 
proportions. 

"It is always well to have in mind a number of these different preparations, 
for it not unfrequently happens that one will answer our purpose when others have 
failed. For fissured nippies some authors strongly advise the application of solid 
nitrate of silver, but our experience does not permit us to speak of it. Dr. John- 
son thinks it is sometimes a good remedy in such cases, at a remote period from 
delivery ; but that during the puerperal state its use is not advantageous, as it is 
apt to be followed by mammary abscess." 

Some excellent remarks follow, in relation to the treatment of mammary- 
abscess, several cases of which are annually admitted into the chronic ward 
of the hospital, in poor women who have been confined at home, or who 
have been exposed to cold and hardship after leaving the institution. The 
points principally insisted upon are, that the matter be permitted to come 
very near the surface, almost until it begins to point, before the abscess is 
opened, but to avoid a spontaneous rupture of the abscess; that when an 
opening is made, it be sufficiently extensive, and outside the areola, lo 
prevent a retraction of the nipple from ensuing. After all inflammatory 
action has subsided, applying to the breast a portion of lint moistened with 
a mixture of one part of spirits of wine, and six or eight parts of water, 
rendered warm before it is used — a very small bit of simple dressing being 
interposed over the orifice of the abscess — answers well, by promoting the 
contraction of the abscess, and removing the indolent and relaxed condition 
which the poulticing produces in the granulations and adjacent integument. 

At a more advanced period, when all tenderness and inflammation have 
completely subsided, but the abscess continues to discharge, the authors 
direct the breast to be strapped with adhesive plaster, which they have 
found a very safe and effectual means for expediting the obliteration of the 
cavity of the abscess. 

" The mode of applying the plaster is as follows: one long, narrow strip is first 
put tolerably tight round the base of the breast, so as partly to insulate the gland; 
other strips are then successively applied in such a manner as to envelope the 
whole, and exert upon it a moderate degree of compression; lastly, a small aper- 
ture, corresponding to that of the abscess, is cut to allow exit to the discharge. It 
is generally necessary, in two or three days, to renew the application of the plaster, 
as it becomes loose and displaced." 

To such of our readers as are engaged in extensive practice, no apology- 
will be necessary for the foregoing notice of subjects which, to the inex- 
perienced, may appear of but trifling importance. To some, it is probable 
that the remarks of our authors may present nothing new, but to the major 
portion the excellent practical directions they inculcate cannot fail to prove 
acceptable, the opportunities for their application being of frequent occur- 
rence. 

The total number of cases of natural labour that occurred within the pe- 
riod to which the report before us refers, was 5842 ; of which 1752 were 
first pregnancies. Sixteen women, seven of whom were primiparae, died 
amongst the natural cases, viz : four of uterine phlebitis, two of peritonitis, 
two of phthisis, one from mania, one of arthritis, one of sloughing of the 
uterus and vagina, one of laceration of the peritoneal coat of the uterus, 
one of pneumonia and bronchitis, one of scarlatina, one of anasarca, and 
one from a tumour compressing the trachea. 

Such of the cases of natural labour as are deserving of particular notice, 
are detailed at length. 



128 



Review. 



[July 



Appended to the cases of uterine phlebitis, we are presented with some 
interesting remarks in reference to the pathology and treatment of that most 
intractable disease. The authors think that there can be no doubt what- 
ever that very many of the cases described by the older writers as in- 
stances of puerperal fever without any local inflammation, were nothing 
more nor less than examples of uterine phlebitis, in which the lesion of the 
veins was overlooked or disregarded ; while of late years, the latter has 
been, in their opinion, a very — -perhaps the most — frequent cause of the 
more insidious and fatal form of the fever of child-bed. 

The following are, they conceive, the principal causes or circumstances 
which most frequently determine, or, in ordinary language, predispose to, 
the development of puerperal phlebitis. 

11 1. Mechanical injury of any kind inflicted on the uterus, as by protracted labour, 
by ■instruments, or by the hand introduced into its cavity. There is hardly any 
operation so much to be dreaded, on account of its after consequences, as that 
required for the extraction of a morbidly adherent placenta. In private practice 
this may not appear so striking, but in hospital practice its truth is beyond ques- 
tion. Dr. Lee seems disposed to attribute the production of metro-phlebitis to 
mechanical injury of some sort, sustained by the uterus during labour. 

" 2. The deiention of a portion of the after-birth or membranes. This gives 
rise to a foul discharge, which may prove a source of irritation to the veins, either 
by absorption or by direct contact with their patent extremities on the internal sur- 
face of the uterus. The absorption of some morbid animal matter being the cause of 
puerperal fever, is no new idea. Mr. Charles White, of Manchester, in his Treatise 
on the Management of Pregnant and Lying-in Women, speaks of this as a fertile 
source of child-bed fevers : and by way of explanation, adds, that the womb is an 
organ, of all others, the most favourably formed to absorb. 

11 3. Hemorrhage. It is a well-established physiological fact, that theloss of blood 
promotes absorption, hence, we can in some measure understand how flooding, 
at the time of labour, operates in rendering women obnoxious to attacks of puer- 
peral phlebitis. The comparatively uncontracted state of the uterus, which accom- 
panies and follows profuse losses in the third stage of labour, is a circumstance 
which also tends to the same result, by leaving the mouths of the veins on the 
raw, internal surface of the organ, incompletely closed. — (Hasse)." "The great 
mortality amongst cases of placenta praevia, where turning has been performed, 
is well known, and in a large proportion of instances, is owing to the supervention 
of phlebitis, whose production here may be ascribed to the joint effect of the 
mechanical injury arising from the introduction of the hand, and the immoderate 
loss of blood. Dr. Merriman states, 'that he has known the phlegmasia dolens 
to follow this species of labour on many occasions.' The close connection sub- 
sisting between this complaint and the one under consideration, is generally ac- 
knowledged. 

Cl 4. Epidemic influence. No reasonable doubt can be entertained as to the 
sufficiency of this cause to call into action morbid derangement, which otherwise 
would not have taken place. Thus, during the prevalence of an epidemic, a pa- 
tient will be attacked with the disease, under circumstances which, in its absence, 
would not have been attended with the slightest unfavourable results. The same 
state of the atmosphere that gives rise to erysipelas would seem to favour very 
much the development of puerperal fever generally, and this form in particular. 
Thus, during the last epidemic of puerperal fever in the Dublin lying-in hospital, 
erysipelas and diffuse inflammation were prevailing to a frightful extent in most 
of the surgical hospitals of the city, in so much that it was with extreme reluctance 
any operation was undertaken. In connection with this, we may be permitted to 
advert to two papers in the Provincial Medical Journal; one by Mr. Storrs, of Don- 
caster, and the other by Mr. Ebrington, of Birmingham, and to another by Dr. 
Peddy in the Northern Journal of Medicine; all of which go to establish the fact 
that puerperal fever of some form — most frequently the phlebitic — maybe induced 
by the fomites or infection conveyed from erysipelas. This affinity or connec- 
tion between the two diseases appears to have been recognized by some of the 



1848.] 



Practical Observations on Midwifery. 



129 



older writers — Pouteau, Home, Young, Lowder, &c. — from their calling puerperal 
fever 'an epidemic erysipelas of the peritonaeum.' In the year 1821, Dr. J. C. 
Douglass's paper on this malady was written, and he therein observes: ' The con- 
tagious puerperal fever of Dublin is, I venture to pronounce, nothing more nor less 
than a malignant fever of a typhoid character, accompanied with an erysipelatous 
inflammation of the peritoneal covering of the stomach, intestines, and other ab- 
dominal viscera. 7 {Dublin Hosp. Reports, vol. iii.) Dr. S. Cusack, in speaking of 
his second or 'low form of puerperal abdominal inflammation, 7 expresses his con- 
viction 'that this disease, if not the same, is at least a modification of that known 
by the name of diffuse cellular inflammation.' The description given by Dr. C. 
of his second form, so exactly corresponds, in its leading features, with uterine 
phlebitis, that we have little hesitation in pronouncing the two to be identical. It 
must be remembered that, "at the time his essay was written (1828), the subject of 
uterine phlebitis was very imperfectly known in this country." (Dr. C.'s paper 
was published in the Edin. Med. and Surg. Journ., vol. xxxi.) 

" Notwithstanding all that has been said or written to the contrary, we think that 
the contagiousness — or, to use the more explicit term suggested by Dr. Chrjstison, 
the ' communicabiiity of puerperal fever in all its forms, is a fact established on the 
most irrefragable evidence, so much so that it would now be almost criminal for 
any practitioner to act on the opposite assumption. 

" Besides the above, which are the principal exciting causes, there are many 
others that are influential in rendering puerperal women obnoxious to attacks of 
metro-phlebitis, viz : mental depression or despondency : broken down or seriously 
impaired health at the time of labour; previous habits of intemperance or dissipa- 
tion • the application of cold, or too early use of stimulants after delivery, &c. In 
proportion as two or more of the above predisposing causes coexist in any indi- 
vidual case, so will the liability of a patient's being attacked be increased. This, 
indeed, is self-evident." 

So important is everything relating to the etiology and pathology of 
puerperal fever, many particulars in relation to which are still involved in 
obscurity, while upon many others there exists a very great difference of 
opinion among the most respectable and authoritative writers, our readers 
will pardon the length of the foregoing extract. Presented as the result of 
strictly clinical observations, the conclusions of Drs. M'Clinlock and Hardy 
are particularly interesting. 

Our authors have very seldom found it possible to decide, with certainty, 
the existence of uterine phlebitis until the symptoms of'the second stage — 
those, namely, which denote the admixture of puriform or septic matter 
with the sanguineous current — make their appearance, as it is these only 
which constitute the true pathognomonic symptoms of the disease. In the 
first stage, the symptoms assume more or less of the character of ordinary 
metritis. - Among the principal of which, are noticed, rapid pulse, uterine 
tenderness and pain, preceded very commonly by rigor, foul tongue, de- 
praved or scanty lochial discharge, tumid abdomen, recession of the milk, 
&c. The most constant of these symptoms is frequency of pulse. In 
some cases, the local distress scarcely attracts attention ; even in these, 
however, an unusual degree of sensibility or tenderness of the uterus 
will be detected on direct pressure being made with the fingers upon 
the fundus and sides respectively of the uterus. The fact of uterine pain 
being sometimes entirely absent even in virulent or fatal cases, clearly shows 
that it is not an essential symptom. 

When fully developed, the diagnostic symptoms of phlebitis constitute a 
most striking and remarkable assemblage. No defined or abrupt line of 
demarkation occurs between the first and second stages, the one passing' 
gradually and imperceptibly into the other. In consequence, indeed, of its 
insidious mode of advance, the disease often makes considerable progress 



130 



JRevieiv. 



[July 



before its true character is suspected, or it may happen that the first une- 
quivocal intimation of its existence will be the appearance of some of its 
secondary affections, such as arthritis, ophthalmia, purulent deposit in the 
cellular tissue or muscles, &c. 

''•The symptoms which usually mark the second stage of uterine phlebitis are 
the following, viz: the occurrence of rigor not referable to any other, cause; ra- 
pidity of pulse ; a peculiar prostrated expression of the countenance, which be- 
comes of a sallow colour; excited action of the arteries, most visible in those of 
the neck; gradually increasing debility; loss of appetite; profuse perspirations; 
diarrhoea; sleeplessness; foul and generally dry tongue; a disagreeable, nauseous 
smell on the patient's breath, most resembling raw meat; muscular tremors; and, 
occasionally, low delirium.' 7 

The vast importance that a correct diagnosis of uterine phlebitis should be 
made in its early stage, from the fact that it is only by an active treatment 
commenced at the very onset of the disease, we can hope to arrest its pro- 
gress in perhaps the majority of cases, has induced us to present here, not- 
withstanding their length, the following observations by Drs. McClintock 
and Hardy on the individual symptoms and their relative importance. 

1. The occurrence of rigors is a very characteristic symptom of phlebitis, but 
it must be remembered that a rigor may arise from other causes; as milk fever, 
ephemeral fever (weed), or incipient inflammation. To estimate its value, there- 
fore, as a diagnostic, it should be taken in connection with all the other symptoms, 
and the history of the case. The rigors of phlebitis may vary in intensity from a 
mere passing sensation of chilliness, to a state of universal shivering, as severe 
as we see in the cold stage of ague. Again, their number, and the periods of 
their recurrence, are liable to great variety in different cases. Examples are not 
wanting where the rigors have assumed a very marked periodicity, with consider- 
able remission of the other symptoms during the intervals — a state of things calcu- 
lated to lead an unwary practitioner into the belief that the patient was labouring 
under some form of intermittent fever. It is rare to find the fits of shivering attack 
a patient more than once in the twenty-four hours, and the seizure may -occur at 
any moment; thus it not uncommonly comes on during sleep, whereupon the 
woman immediately awakes. The recurrence of the rigor within twenty-four 
hours is a circumstance which, in itself, almost unequivocally points out the ex- 
istence of phlebitis, as such is never known to happen in ephemeral or milk fever. 
Some patients acquire an instinctive horror of the rigors, and view their returns 
with a feeling of vague apprehension and dread. • We have seen many fatal 
cases of metro-phlebitis, in which there had been but a single rigor throughout 
the whole course of the disease, and occasionally this w 7 as a very slight one. As 
the result of our past experience, we think there is hardly any single symptom 
which should be regarded with more suspicion and alarm in a puerperal patient, 
than a rigor, when it cannot be distinctly traced to milk fever or weed. We have 
soraeiimes observed a slight degree of rigor to follow, and apparently to have been 
induced by the act of evacuating the bowels, particularly if diarrhoea were present. 

" 2. A short time before the accession of a fit of shivering, the pulse usually falls 
considerably in frequency, so that if reckoned by the physician at this time, he 
might be incautiously led to give an opinion which the occurrence of the next 
half hour, perhaps, would induce him to retract. In the reaction following the 
rigor, the pulse invariably becomes much accelerated, but generally subsides 
again, in the course of a few hours, to its former standard, whatever that may 
have been. Its average frequency between the rigors varied from 100 to 120 or 
130; in a few instances, it was so low as 90 or 84, and this, we think, is to be re- 
garded as a very favourable prognostic. In cases where the pulse was rapid, we 
have generally found that it had a sharp, vibrating feel under the finger, though 
not conveying the idea of strength or fullness, but partaking rather of the hemor- 
rhagic character. It might well be denominated an 'irritable pulse.' Generally 
the first symptom of improvement in the state of the pulse was its losing this sharp- 
ness, and becoming soft and yielding to the touch; indeed, until it had assumed 



1848.] 



Practical Observations on Midwifery. 



131 



this, its healthy character, there was seldom any real amendment, even though a 
diminution in its frequency might have taken place. 

" 3. Biarrhcea and a tumid .state of the abdomen, from flatulent distension, were 
very constant, but not invariable attendants upon the second stage of puerperal 
phlebitis in the examples that have fallen under our observation. Even in those 
instances where diarrhoea was absent, there was a degree of irritability of the 
bowels which required much care and circumspection to be exercised in regulat- 
ing the diet and medicines. On account of this symptom the mercurial treatment 
could seldom get a fair trial, even though every precaution was used to guard 
against its running off by the bowels. The evacuations chiefly consisted of a 
brownish liquid possessing a most intolerably offensive smell. On the first ap- 
pearance of diarrhoea, and frequently before it commenced, the most scrupulous 
attention was paid to the patient's food and drinks, as well as to the medicines. 
The remedy on which most reliance was placed for controlling the diarrhoea, w^as 
opium in some form, the ordinary astringents having been found wholly ineffec- 
tual in most cases. Acetate of lead, in solution, with acetate of ^morphia, some- 
times had the desired effect of moderating the purging, when other astringents 
had failed. As a last resource, the abdomen has been blistered, and very often 
with satisfactory results. 

' : 4. The tongue very commonly presents some unhealthy appearance, but this 
will, of course, much depend upon the state of the stomach and bowels. Gene- 
rally it is covered with a thick, whitish coating, and when amendment begins to 
take place, it cleans from the tip and edges. So far as our experience goes, the 
most unfavourable condition of the tongue is that of dryness, with its middle of a 
brown colour. We lately saw a case of well marked puerperal phlebitis, in which 
the tongue remained clean and moist until a very few days before dissolution, 
when, for the first time, it presented a slight brown streak dowm the centre, which 
was less moist than the adjoining parts; this gradually increased till the whole 
upper surface of the organ assumed a mahogany colour. This patient, all through 
her illness, was quite free from gastro-enteric derangement of every kind, except 
some little irritability of stomach. 

" 5. Vomiting is a symptom we have, comparatively speaking, rarely seen in 
pure uterine phlebitis-, and never almost to any great extent. We feel disposed to 
consider it as more indicative of peritonitis than of phlebitis. When it does come 
on, it is usually towards the close, and is associated with other gastro-enteric 
symptoms. 

11 6. Throughout the second stage, the skin is generally bedewed with moisture, 
and when the complaint is drawing near to a fatal termination, profuse sweating, 
particularly during sleep, is a constant attendant. A miliary rash on the neck 
and chest very often accompanies this symptom." 

"The secondary affections of metro-phlebitis are numerous. Those which we 
have seen comprise the following, viz., arthritis: abscesses in the muscular and 
cellular tissues, and in the parotid gland; pleuritis ; inflammation of the eye; 
ulceration of the intestines ; eruptions of large, purulent bullae, or miliary vesicles, 
on the skin; inflammation of the lungs, &c. As to the period at which these 
make their appearance, there seems to be great latitude — a few days being suffi- 
cient for their production in some instances, whilst in others they will not occur 
at all, even though the patient may linger on for several days or a fortnight." 

Our authors do not recollect having- ever seen an example of uterine 
phlebitis coming on in the second week after delivery, where the patient 
had passed through the first seven days without any unfavourable symp- 
tom. 

The treatment recommended during the first stage of the disease is the 
antiphlogistic— general and local bleeding, the warm bath, and the adminis- 
tration of mercury so as to affect the system. It was a trite observation in 
the Dublrn Hospital that if once decided ptyalism could be induced, recovery 
might almost be deemed certain. In the second stage, when the more 
characteristic features of the disease have become developed, the treatment 



132 



Review. 



[July 



is almost wholly empirical, or directed with a view to relieve urgent symp- 
toms. Mercury in this stage is rarely admissible. 

'•'The leading indications to be fulfilled are: 1st, to relieve or mitigate any ur- 
gent symptoms, such as diarrhoea, sleeplessness, vomiting, &c; 2d. lo support the 
strength by diet, as mild and unstimulating as possible ; and, lastly, to enjoin the 
strictest rest of mind and body— to confine the patient to the horizontal position in 
bed — to prevent every source of excitement, moral or physical — and, in short, to 
adopt, with unremitting vigilance, every means calculated to tranquilize the sys- 
tem, and to abate or ward off inflammatory action. For checking the diarrhoea 
and procuring rest, opium is the sheet-anchor; from amongst its many prepara- 
tions we can seldom fail of finding some one to answer the ciicumstances of each 
particular case. Where great hurry of the circulation existed, we have seen 
marked benefit from the administration of digitalis orprussic acid, given in divided 
doses, and combined or not with a small opiate, according to the state of the bow- 
els. So far as our experience enables us to judge, we should say that stimulants 
will very rarely be found beneficial in the treatment of uterine phlebitis: they have 
always seemed to aggravate the existing symptoms, and to increase the febrile 
disposition, which should be especially avoided. In one case of marked uterine 
phlebitis, where the prominent symptoms were rigors and colliquative sweats, we 
gave trial to the use of nitro-muriatic acid, but without any apparent success. 77 

We have endeavoured to lay before our readers a tolerably full account 
of the views of our authors in relation to uterine phlebitis; in doing this, 
we have been led into quotations which may appear to some of unreasona- 
ble length, but the fearful character of this form of puerperal disease — the 
unsettled state of medical opinion in relation to its causes and treatment 
— and the very valuable information comprised in the clinical observations 
of Drs. McClintock and Hardy, must be our apology if we have transcended 
the usual privilege of reviewers. It is probable that it is through our digest 
and quotations alone that these observations will reach a large proportion 
of our readers. We may remark that, in all the more important particulars, 
the observations of our authors coincide with our own. We have not, it is 
true, seen the very decided good effects result from direct depletion, which 
they ascribe to it in the first stage of the disease; copious bleeding appeared 
to us to be more decidedly beneficial in the more frequent form of puerpe- 
ral fever dependent upon peritoneal inflammation ; or in which, as correctly 
remarked by our authors, inflammation, commencing in the uterus, spreads 
from thence, with more or less rapidity, over a greater or less extent of the 
serous membrane of the abdomen. 

vSome interesting observations are contained in the present section, in 
reference to the pathology and treatment of phlegmasia dolens. Although 
fully satisfied of the general correctness of the doctrine which ascribes this 
disease to phlebitis, yet the authors would not go so far as to say that every 
case was caused solely by venous inflammation. In regard to treatment, they 
advise that the patient be strictly confined to bed, and kept in the horizon- 
tal position. In the acute stage, a diet of the simplest and most unstimu- 
lating kind. The affected limb to be fomented frequently with soothing 
applications, and leeched over the seat of greatest tenderness; after the 
leeches fall off, to be followed by a soft, light poultice. The external use of 
mercury they have found generally beneficial, when carried so far as to 
gently affect the system, and produce slight ptyaiism. Next to mercury, 
in the list of remedies, they place James' powder, and diuretics, the former 
being given alone or combined with blue pill or Dover's powder, according 
to circumstances. After the gums have been touched, diuretics are to be 
exhibited, unless diarrhoea be present, in which case astringents must be 
employed, particularly opium ; after the very acute symptoms are subdued, 



1848.] 



Practical Observations on Midwifery. 



133 



blisters will be found of much benefit. So soon as all febrile and inflamma- 
tory symptoms are removed, a more generous regimen, and a less depressing 
line of treatment, may be gradually and cautiously commenced with. To 
remove the swelling and stiffness of the limb, our authors recommend gen- 
tle frictions with any discutient liniment, and subsequently bandaging with 
a flannel roller, from the toes to the top of the thigh. As the patient ex- 
hibits symptoms of amendment, some gentle tonic, as the infusion of gentian, 
may be prescribed, the value of which would appear to be generally aug- 
mented by the addition of a diuretic; subsequently, the quinine has been 
found to act most efficaciously in restoring the appetite and tone of the sys- 
tem. "The swelling, in this stage, has generally all the characters of 
oedema, and when the limb is indented with the finger, the impression will 
be retained for some time ; whereas, in the early stage of the disease, the 
integument is tense and elastic, and does not usually pit on pressure." 

From what our authors have seen of puerperal mania, they would for 
practical purposes arrange the different cases of it into three classes. 

The first including all those cases where there is a highly excited state 
of the circulation and system at large, but without any evidence of cerebral 
inflammation. The skin will be hot and dry; the puise rapid, sometimes 
extremely so, and the patient disposed to be noisy and talkative. In this 
form of the disease, according to Drs. M'C. & H., tartar emetic in divided 
doses is superior in efficacy to any other remedy with which they are ac- 
quainted. In this, as in other forms of puerperal mania, the liver and ali- 
mentary canal are generally in a deranged condition. Where constipation 
was present, blue pill or calomel was administered and followed by a pur- 
gative draught. A narcotic was occasionally given at bed-time, provided 
that no indications of cerebral congestion or inflammation were present. The 
extract of conium, or hyosciamus, was usually preferred, but if this did not 
procure sleep, the solution of acetate of morphia, or the black drop, was given. 

In the second class are arranged those cases where the mania is attended 
with inflammation of the brain or its membranes, which serious complica- 
tion will of course demand the energetic employment of all the established 
means for the treatment of phrenitis. This is a comparatively rare form of 
the disease. 

The third class of cases are those in which the impairment of reason 
occurs as a solitary symptom, unaccompanied by any marked bodily de- 
rangement. The pulse is little above the natural standard, the skin is cool, 
and there is no headache or flushing of the face. The character of the 
insanity does not seem to be subject to any fixed law, but more commonly 
the patient is gloomy and taciturn, and rarely excited or violent. The plan 
or treatment that was adopted in these cases chiefly consisted in correcting 
the state of the bowels when they were disordered, and administering 
anodynes at night. Preference was usually given to the extract of hyos- 
ciamus with camphor; the solution of the acetate of morphia, or the black 
drop being substituted where there was much vigilance. 

"There is," our authors remark, 11 a fact of much practical interest connected 
with our present subject, which we may here allude to, namely, that abdominal 
inflammation sometimes alternates with the alienation of reason, and this at a 
period after delivery when the patient is usually considered free from the liability 
to such attacks. A remarkable instance of this was related to us by Dr. Johnson. 
A patient some days after delivery became maniacal, and in this stale continued 
for a week, when she regained the possession of her intellect, but to this imme- 
diately succeeded violent peritonitis, which carried her off. A neatly similar 
occurrence took place in another instance, whose history we have given at length. 



134 



Review. 



[July 



Sri Case XXVI. of the present chapter, it may be observed that, after the patient 
was attacked with mania, the symptoms of uterine inflammation almost entirely- 
disappeared, but upon the return to consciousness they again became apparent. 
We lately saw a fatal case of puerperal mania, of the low, melancholic form, with 
rapid pulse, in which, on examination after death, there was found most extensive 
peritonitis, with copious lymphy exudation, although during life she had not ex- 
hibited a single symptom to lead to a suspicion of the existence of abdominal 
inflammation. 

u Nearly all the cases of puerperal mania that we have ever seen, occurred 
within the first week or ten days after parturition." 

The ensuing section of Dr. McC. and H.'s work is devoted to observa- 
tions on several points connected with the management of tedious and 
difficult labours. These are particularly interesting, as comprising the 
results of an experience which in its extent is seldom attained by the most 
extensive practitioners of midwifery during a protracted professional career. 

In all cases of tedious labour that have come under the observation of 
the authors where the first stage was unusually prolonged, the cause 
almost invariably has been a rigid unyielding condition of the os uteri. 
These cases occurred exclusively among primiparous females, and more 
commonly among those in whom the membranes had ruptured at an early 
period of the labour. In the Dublin Hospital the treatment of cases attended 
with a rigid and undilatable state of the os uteri consists chiefly in the use of 
tartarized antimony, venesection, and the warm bath, the bowels being first 
well freed. The remarks of the authors upon the Cases and circumstances 
in which the lancet should be preferred, are particularly excellent ; they are 
too long, however, to quote. 

Tartar emetic was given in almost every case where the first stage of 
labour was protracted beyond a reasonable time. We are advised against 
its use, however, until we are satisfied of the existence of true labour pains. 
In doubtful cases, where the pains appear of a mixed or irregular character, 
bleeding has been the practice most commonly adopted in the hospital, 
inasmuch as it is calculated to prove beneficial whether they be true or 
spurious. 

The warm bath is never resorted to except in cases of obstinate rigidity, 
which had proved rebellious to every other treatment; hence the number 
of instances in which it has been necessary to employ the bath is extremely 
limited — being for the three years to which our authors' observations espe- 
cially refer, about one out of every thousand labours. From the result of 
some of the cases which fell under their notice, the impression was made 
on their minds, though, perhaps, without sufficient reason, that it exerted 
an injurious effect upon the foetus. 

In their review of the remedies employed for delay in the second stage 
of labour, they first speak'of ergot of rye. This article is pretty extensively 
used in the hospital in cases of arrest, and in the treatment of hemorrhage 
after the separation of the placenta. The cases of tedious labour in which 
it is almost exclusively employed, are, 1st, where the delayoccurred in the 
second stage solely from inert uterine action. It is only whea impelled by 
unavoidable necessity, that the ergot is ever given in any other cases. 
"For, independent of considerations towards the mother's safety, experi- 
ence has amply proved that the child will undoubtedly perish unless delivery 
be accomplished within a limited time after having exhibited the ergot, and 
therefore it is an important desideratum that the use of the forceps be 
feasible before resorting to the administration of this remedy." 

2d. The second class of cases in which the ergot was employed, "were 



1848.] 



Practical Observations on Midwifery. 



135 



those in which the fetal head, without any discoverable pelvic deformity to 
account for it, became arrested in the brim of the pelvis, and remained in 
this position until bad' symptoms began to develop themselves. 

11 Under these circumstances, if the fetal heart were at* all audible, the ergot of 
rye was administered; in the hope that it might bring the head within the reach 
of the forceps. It may be inferred, from what has preceded, that the ergot was 
very reluctantly given in these cases, and that it was the accession of bad symptoms 
only which prompted its employment. Examples of this class were extremely 
unfrequent, and almost invariably occurred amongst primipavae." 

" The third class of cases where the ergot has been had recourse to, includes 
those instances in which unfavourable symptoms, calling for delivery, manifested 
themselves whilst the fetal heart was still audible, but where the use of the forceps 
or vectis was inadmissible. It is not to be supposed from this, however, that these 
were cases of obvious pelvic deformity, or impaction of the head, properly so 
called; if such had existed, it is needless to say this line of practice would not 
have been pursued. The use of the forceps or vectis was prohibited from the 
insufficiency of space, and from the state of the soft parts being such as to render 
their employment hazardous in the extreme, and calculated to expose the patient 
to the imminent risk, if not positive certainty, of frightful laceration or sloughing 
of the vagina, and this, too, with a very remote chance of rescuing the infant. 
From the known influence of ergot upon the child, if delivery be delayed beyond 
a certain time, it was never given in any of these cases until it became obvious 
that the preservation of the mother's life peremptorily called for assistance." 

The employment of ergot in the second class of cases, strikes us as unne- 
cessary, if not of doubtful propriety. The third class of cases in which the 
remedy is stated to be employed in the Dublin Hospital, we either do not 
clearly understand, from the description given above, or we should certainly 
apprehend positive injury from the administration in them of ergot. The 
attempt to force onward the fetal head by stimulating the uterus to increased 
action, when there is not sufficient space for the application of the forceps, 
we should very much fear would eventuate in a rupture of the uterus. 

The authors' remarks on the choice and employment of instruments will 
not be particularly satisfactory to the American practitioner. The time for 
employing both the vectis and forceps, and the manner of introducing them 
as laid down by our authors, are in strict accordance with the directions of 
Denman. As the use of the long forceps is entirely excluded in the wards 
of the Dublin Hospital, it is evident that in cases in which instrumental 
interference is indispensable, some lime is necessarily lost, and consequently 
the chance of saving the life of the child considerably diminished. The 
frequency with which the perforator and crotchet are resorted to, will sur- 
prise the obstetricians of this country. We cannot say that the reasons 
adduced by the authors in favour of resorting to embryulcia rather than the 
forceps, are entirely conclusive. Their remarks on the employment of 
auscultation to. determine the condition of the fetus, are deserving of 
attention. 

The total number of tedious and difficult labours included in our authors' 
report, amounts to 259, — of which 173 were delivered without any instru- 
mental assistance. In 52 instances, delivery was effected by the perforator 
and crotchet, in 18 by the forceps, and in 16 by the vectis or lever. In 88 
cases, the principal delay was in the first stage ; in 1 19, in the second stage; 
and in 52 cases, both stages were protracted. Twenty-two women died 
out of the 259, and nineteen out of these fatal cases were primi parous 
women. Of the children we find that 154 were boys, of whom 83 were 
born alive, and 105 were girls, of whom 56 were born alive. 

Of the 173 delivered without instrumental assistance, 30 got ergot to 



136 



Review. 



[July 



overcome inertia in the second stage of labour, and only 10 out of the 30 
children were born alive. 

" This furnishes strong proof, were any such required, of the deleterious influ- 
ence of ergot upon the foetus, as in nearly every one of the above instances, there 
was unequivocal evidence of the child's vitality when the ergot was given, and 
in the great majority of them delivery took place within two or three hours after 
the administration of the medicine. ;; 

In the instrumental cases, 34 in number, 17 of the children were born dead. 

Detailed histories are given of the more important of the cases of tedious 
and difficult labours, and a general table is appended showing the age of 
each patient, the presentation, duration of labour, whether it was first, 
second, or third pregnancy, &c, sex of child, whether born alive or dead, 
stage in which delay occurred, mode of delivery, and result to mother. 

The third section comprises observations on preternatural labours. The 
directions for the management of breech and footling cases are judicious, 
but present nothing with which the American obstetrician is not perfectly 
familiar. 

The authors remark, that of all the breech and footling cases which 
have come under their observation, in about one-third, they should think, 
the child entered the pelvis with its face looking towards the abdomen of 
the mother; yet in no instance was it delivered face to pubis, and in very 
few was it requisite to give even the slightest assistance to nature in 
making the turn, whereby the back of the infant is brought round to cor- 
respond with the forepart of the pelvis. 

The total number of the preternatural presentations included in the re- 
port before us, amount to 227; of which 101 were breech cases, exclusive of 
those (39 in number) which occurred amongst the twin cases. Of the 101 
children who presented with the breech, 37 were dead born, 21 of which 
were putrid: 24 were premature, of which 18 were still-born, 13 being in 
a putrid condition : of the six. born alive, one was at the sixth month ; three 
at the seventh, and two at the eighth ; two were boys, and four girls. 
Nine of the premature still-born children were males; and 23 of the entire 
number of the still-born. Of the 101 breech cases, 58 were males and 43 
females. Three of the mothers died. 

The section concludes with a brief statement of such of the cases of pre- 
ternatural labour as seem worthy of notice, and a general table, as in the 
cases included in the preceding section. 

Some interesting remarks are made by our authors on the subject of 
turning in shoulder and arm presentations. 

In arm cases they state that they have found great benefit from the use 
of tartar emetic, from its relaxing effects upon the os uteri, as also in those 
cases where it was an object to moderate or subdue uterine action, prepa- 
ratory to introducing the hand for the purpose of turning. They give it 
in one-sixth, or one-fourth of a grain doses, repeated at intervals, varying 
in length, according to the urgency of the case, or until it produced the 
desired effect, or brought on full vomiting. 

" Indeed/' they remark, a it is a very usual practice, in all cases of arm presenta- 
tion, to exhibit small doses of tartar emetic solution before the os uteri is fully 
dilated, with a view to prevent the accession of strong uterine action, and to favour 
the relaxation of the soft parts. This plan is al>o followed in cases where the 
presenting part is not clearly ascertained ; the antimonial solution being given in 
email quantities, until the os be fully dilated, or the membranes ruptured; after 
which its further administration is regulated by circumstances." 



1848.] 



Practical Observations on Midwifery, 



137 



In turning, the authors advise the bringing down of one leg only, taking 
hold of either knee orfoot, whichever should happen to be the most con- 
venient and accessible. They point out in a very striking manner the ad- 
vantages which recommend this mode of turning, and have led to its adop- 
tion in the Dublin Hospital as the usual practice. 

The fourth section embraces observations in reference to complex labours. 
A very full examination is entered into as to the proper treatment of pla- 
centa prsevia. After pointing out the extreme difficulty of diagnosis be- 
tween those cases in which the hemorrhage results from the implantation 
or encroachment of the placenta upon the os uteri, and accidental hemor- 
rhage from other causes, in the commencement of an attack, when the 
os uteri is high up and undilated, and no pains are present, the authors 
remark — 

" In all cases of accidental hemorrhage and partial presentation of the placenta, 
where the membranes could be felt at the os uteri, the established practice (in the 
Dublin Hospital) was to rupture them, either with the fingers or a blunt stilette, 
should the discharge of blood be immoderate, or prove uncontrollable by the ordi- 
nary means. If this did not induce an amount of uterine contraction sufficient to 
repress the hemorrhage, other means of a similar tendency were resorted to, such 
as friction over the uterus, stimulating enemata, or, if the state of the parts would 
admit, the ergot of rye, unless much exhaustion or depression of the vital energies 
was present. Such a condition of the patient always renders the use of ergot ex- 
tremely hazardous, as the effect of this medicine upon the system is itself depress- 
ing. It very rarely happens, however, that rupturing the membranes is not an 
effectual means for suppressing the hemorrhage in cases such as have been just 
described ; and there can be no question but that it is a much safer proceeding 
than introducing the hand and turning. If the pains come on, we may rest as- 
sured that the effusion of blood will be restrained ; and if the uterus be not excited 
to action, and if the hemorrhage continue, that no great difficulty can be experienced 
in the operation of version. But we must again repeat, that a case in which the 
ulterior measure of turning will be called for, is extremely rare. Our personal 
observations lead us to this conclusion, which is further corroborated by the more 
extensive experience of Dr. Johnson. Where the patient is much reduced before 
the operation of puncturing the membranes, it is most desirable that labour should 
not set in for some hours, provided, of course, that the great object of our inter- 
ference, the arrest of the hemorrhage, shall not have been achieved; as the 
respite will allow time for the strength to be recruited before any further demand 
is made upon her enfeebled bodily powers. Under circumstances of this kind, 
where the hemorrhage has been controlled by letting off the liquor amnii, but the 
patient is miserably weak, it becomes a question worthy of serious consideration 
whether a full opiate may not prove beneficial, by deferring the accession of 
labour pains to a more favourable time. We have seen it administered with this 
intention, and have had reason to be much gratified at the result." 

Placenta prsevia occurred, on an average, only once in 1500 cases, accord- 
ing to the combined statistics of Drs. Joseph Clarke and Collins, and of our 
authors; and if we exclude the instances of partial presentation of the pla- 
centa, which did not require turning, its frequency will appear still lower. 
Our authors have not observed that any constant or uniform proportion 
existed between the quantities of the hemorrhage and the extent to which 
the placenta has covered the os uteri. They have seen as profuse and 
alarming losses of blood where there was only an edge presenting as in 
any other cases. 

Delivery by turning the child they would almost restrict to cases where 
there is a complete, or nearly complete implantation of the placenta over 
the mouth of the uterus, or where the hemorrhage is not arrested by the 
rupturing of the membranes. 



138 



Review. 



[July 



Previously to the os uteri being sufficiently dilated to render the passage 
of the hand practicable, reliance is placed for the arrest of the discharge on 
the use of the tampon, together with the strict observance of all the general 
rules applicable to every case of uterine hemorrhage. The tampon was 
only resorted to in the hospital in cases where the entire mouth of the 
uterus was covered by the placenta, and whilst it was in a state to obstruct 
the entrance of the hand. Confining the tampon to such cases very much 
lessens the liability to internal hemorrhage — such, at least, is the experience 
of our authors. It is well, however, they remark, always to bear in mind 
the possibility of this serious occurrence, and to keep a close watch over 
the patient as long as the tampon remains in the vagina. 

To the plan recently proposed by Drs. Simpson and Radford, of extract- 
ing the placenta before the child, in cases of placenta prsevia, Dr. Johnson, 
it is stated, entertains very strong objections, not only because it necessa- 
rily destroys the child, but also from a conviction of its inapplicability to 
cases of rigid os uteri, which is the chief or almost only obstacle to the per- 
formance of version in these cases. 

Our authors doubt, and with propriety, we think, the correctness of Dr. 
Simpson's doctrine, that the hemorrhage in cases of placenta praevia issues 
principally or entirely from the vascular openings on the exposed placental 
surface ; they cannot persuade themselves that the great amount of the blood 
discharged does not proceed from the uterine vascular orifices. 

Some interesting remarks follow on the circumstances under which the 
exhibition of opium may be expected to prove beneficial in this as well as 
in the accidental species of flooding. 

The authors lay down, with great precision and judgment, the rules for 
the prevention of hemorrhage immediately after delivery. They arrange 
these under three heads ; viz., first, such as are calculated to secure a tran- 
quil state of the circulation at the time of delivery; secondly, judicious 
management of the second stage of labour; and, lastly, under certain con- 
ditions, the use of ergot of rye; we can spare room only to notice the authors' 
remarks on the latter. 

In the hospital such decidedly favourable results have been experienced 
from the administration of ergot as a preventive of post-partum hemorrhage, 
that they have no hesitation in pronouncing the practice to be both safe 
and efficient. 

"It may be given at one or other of three periods: namely, when the head of 
the child is on the perinaeum. and about to be expelled; or immediately after the 
head has cleared the os externum, and before the shoulders have passed; or, 
thirdly, as soon as the insertion of the cord into the placenta can be felt. By 
giving ergot before the child has been expelled, some time may be gained, but 
should the placenta be morbidly adhering to the uterus, the difficulty of intro- 
ducing the hand for its removal will be greatly increased. By adopting the third 
plan, this source of apprehension is avoided. To this method it may be objected 
that much time will, perhaps, elapse, and a considerable quantity of blood be lost, 
before the ergot is administered; nevertheless, the possibility of the placenta being 
morbidly adherent, should be ever present in the mind of the practitioner, and 
deter him from resorting to a measure which may so greatly augment the danger 
of the complication. Dr. Johnson, who introduced the practice, generally gives 
the ergot according to the mode last recommended. In certain instances, how- 
ever, where from previous losses it was a matter of the utmost importance to pre- 
vent any further hemorrhage after delivery, we have not scrupled to administer 
it in the second way spoken of above, and hitherto without any unpleasant effect." 

The author's directions for the management of hemorrhage occurring 
between the birth of the child and the expulsion of the placenta, are excel- 



1848.] 



Practical Observations on Midwifery* 



130 



lent, but present nothing with which the American obstetrician is not fami- 
liar. The directions laid down by them for the arrest of hemorrhage occur- 
ring subsequent to the expulsion of the placenta, are equally judicious. 
Were we not fearful of extending this review to too great an extent, we 
should be tempted to present an extract or two from this portion of the 
work. 

Under the head of Retention of the Placenta, after laying down the gene- 
ral rule that the introduction of the hand for the removal of the after- 
birth is never to be performed, unless from a well-grounded conviction of 
its imperative necessity, our authors remark, that out of all the cases, 
amounting, probably, to upwards of two hundred, in which they have seen 
ergot of rye given before the birth of the child, there was only one instance 
in which the after-birth was not expelled by the natural efforts, aided occa- 
sionally by external pressure on the uterus, and in this solitary case it was 
retained from inertia: Had there been, however, they remark, a morbid 
adhesion of the placenta in any of these cases, it is more than probable 
that the difficulty of detaching and bringing it away, would have been 
increased by the previous exhibition of the ergot. 

In the cases included in the report before us, there occurs only one in- 
stance in which hour glass contraction of the uterus was the cause of the 
retention of the placenta. Dr. Johnson adopts the opinion of Dr. Douglass, 
that hour glass contraction should only be considered as a secondary cause 
of detained placenta, its formation being merely the result of the undecided 
manner in which the practitioner introduces or attempts to introduce his 
hand, with the intent to extract a placenta retained by inertia or morbid 
adhesion. The experience of our authors is in confirmation of this opinion. 
They think it very likely that the scrupulous attention paid in the hospital 
to the application of the binder, and also the practice of keeping a steady 
pressure on the uterus wjiilst the child is being expelled, and afterwards, 
must tend materially to lessen the frequency of retained placenta, by pre- 
venting irregular contraction, or inertia of the organ. 

It was the invariable practice in the hospital, only deviated from in cer- 
tain cases of abortion, never to exhibit the ergot to any patient in the third 
stage of labour, until the placenta had come away, or was completely de- 
tached, and lying in the os uteri or the vagina. The reason for this is the 
impossibility of diagnosing in each instance the precise cause of retention ; 
for, although they do not deny that where the placenta is retained from 
inaction of the uterus, the ergot might be advantageous, yet where the reten- 
tion is owing to an abnormal adherence, it would only aggravate the dif- 
ficulties of the case. 

Whatever may be the precise cause of the morbid union between the 
maternal surface of the placenta and the uterus, our authors believe there 
can be little doubt but that an inflammatory process very frequently attends 
its formation, and, in all probability, conduces to increase the evil. Hence, 
they insist, when evera pregnant woman presents herself with localized 
pain or tenderness of the uterus, the first inquiry is to ascertain with the 
stethoscope, whether the painful part be over the attachment of the pla- 
centa, as in that case the prognosis should be more grave, and the cura- 
tive measures more prompt and active. 

This section, the same as the preceding ones, presents a detail of nume- 
rous individual cases, and general statistical tables. 

The next section is devoted to observations on puerperal convulsions. In 
regard to the premonitory symptoms of the attack, our authors remark — 



140 



Review. 



[July 



11 111 a disease so justly dreaded, and so full of danger as puerperal convulsions, 
it is satisfactory to know that there very generally exist some precursory symp- 
toms of a sufficiently obvious character, to lead one to anticipate its attack, and by 
the timely use of proper measures, to prevent it altogether, or materially lessen 
its violence. Amongst the cases of convulsions that have fallen under our obser- 
vation, warnings of this kind were, upon close inquiry, very seldom found to have 
been absent, although they were not always equally striking or manifest. The 
most constant of these premonitory symptoms are headache, varying in kind and 
degree, but generally of a dull, obtuse, or tensive character, and liable to be in- 
creased upon exertion, particularly upon stooping: an cedematous condition of the 
face and upper extremities, most visible in the morning, soon after rising ; a furred 
tongue and sluggish state of the bowels. (Edema of the lower limbs has been 
considered by Dr. Hamilton and others, as a very certain precursor of eclampsia, 
but our experience is at variance with this, and we would, with Dr. Johnson, be 
disposed to regard cedema, confined to the face and hands, as more decidedly pre- 
monitory of convulsions. In some cases, the above symptoms were more promi- 
nently marked than in others, or were accompanied by one or more of the fol- 
lowing: viz., vertigo, tinnitus aurium : flashes of light before the eyes, or muscce 
volitantes ; temporary loss of vision, or of consciousness ; flushed face; pain at the 
epigastrium; and an albuminous state of the urine. Dr. Lever was, we believe, 
the first to draw attention to the state of the urine in this class of patients, and to 
show that in them it very constantly presents albuminous characters. Not only 
has he found this condition of the secretion in women actually labouring under an 
attack of the disease, but what more concerns our present purpose, his investiga- 
tions have led him to think that it frequently exists for some time previous to the 
convulsive seizure, so that it may be included in the category of premonitory 
symptoms." " We have examined the urine in some cases where convulsions 
were present, and in several others where they were threatened, and the general 
tenor of the results coincided with those of Dr. Lever. His conclusions receive 
additional confirmation from the researches of MM. Devilliers and Regnault. — 
(Revue Med., Mars 1847.)" 

The prophylactic treatment recommended by our authors, consists in 
blood-letting, followed, if necessary, by leeches to the temples ; a mercurial 
purgative, the regular action of the bowels being subsequently kept up by 
appropriate laxatives ; exposure to the open air, daily exercise, and an 
unstimulating diet. 

"In cases where the predisposition is strong and difficult to eradicate, besides 
using these remedies, Dr. Johnson is in the habit of giving James' powder, after 
the following manner : He begins with a small dose at bed-time, and continues in- 
creasing it every night by one grain, until it produces some sensible effect, or 
until the dose amounts to "ten or twelve grains, when it is omitted. Should there 
be any vascular excitement, or should the kidneys not be acting properly, digitalis, 
with dried soda, may be given in divided doses." 

Of the truth and importance of the remarks made by Denman and con- 
firmed by Dr. Collins and other observers, that there exists a strong tend- 
ency to peritoneal inflammation in cases of puerperal convulsions, our 
authors are fully assured. So remarkably strong and difficult to eradicate 
is this predisposition, they remark, that in several instances they have 
seen metritis manifest itself in patients who had been only threatened with 
convulsions, the fits having been warded off by an appropriate treatment. 

One of the well-established facts connected with puerperal convulsions, 
is that the vast majority of instances occur among women pregnant of their 
first children. Ten of the thirteen cases recorded by our authors were 
primipara. 

" It rarely happens," they remark, u that a woman is attacked with convulsions 
in her second labour who has not had them in her first; but when such does take 



1848.] 



Practical Observations on Midwifery. 



141 



place, we believe it may be often accounted for in this way, that either preventive 
treatment had been adopted in the first pregnancy, and not in the second, or else 
that the second labour was more tedious and prolonged than the first, for delay in 
the labour unquestionably tends to favour the development of the disease. In the 
thirteen cases related in this report, as well as in all others that have come under 
our observation, the head was the presenting part, which agrees with the experi- 
ence of Dr. Joseph Clarke, Labatt, Collins, and Johnson. Each of the two latter 
physicians, however, saw one convulsive case, in which the head was not the 
presenting part. 

11 It does not appear that females who are subject to epileptic fits are more liable 
on that account to attacks of puerperal convulsions. On the contrary, it would 
seem that they enjoy an exemption, and that even the epileptic attacks occur with 
less frequency, and with mitigated severity, during pregnancy. This certainly 
was ihe case in three or four instances of pregnant epileptic females who came 
under our notice." 

The means upon which chief reliance was placed, in the Dublin Hospi- 
tal, for the treatment of puerperal convulsions, were copious blood-letting, 
free evacuation of the bowels, cold affusion of the head and face, and the 
administration of tartar emetic as first recommended by Dr. Collins. The 
latter is commenced with so soon as the bowels have been well emptied ; 
two grains of the salt are dissolved in four ounces of distilled water, with the 
addition of one scruple of tinct. opii, and a tablespoonful of the mixture is 
given every hour, or half hour, according to the urgency of the symptoms. 

£{ From the known liability to uterine or abdominal inflammation after an attack 
of puerperal convulsions, it was customary in the hospital to direct occasional 
small frictions with the mercurial ointment, and also to give some blue pill at in- 
tervals, during the first few days after delivery. The object of this was to prepare 
the system, so that in the event of inflammatory action supervening, mercuriali- 
zaiion might be produced with as little delay as possible." 

Detailed histories are presented of all the cases of puerperal convulsions 
which occurred in the Dublin Hospital during the period embraced in the 
report before us. Of these, ten were first pregnancies, and three were 
second pregnancies ; two of these latter had had convulsions in their first 
labour, and in the third case, an interval of ten years had taken place since i 
the birth of the first child. In ten cases, the convulsions came on before 
delivery, and in two of these, they continued after delivery ; in three in- 
stances, the attack did not begin until after delivery. Six of the children 
Were males, and seven females ; of those born alive, three were boys, and 
four girls. Six of the women were delivered naturally; four by the 
crotchet, two by the forceps, and one by the vectis. Three cases termi- 
nated fatally. 

Rupture, of the uterus is the subject next treated of. The observations 
presented by our authors on this serious accident are particularly inte- 
resting. The circumstances they have been taught to regard as the har- 
bingers of a rupture of the uterus are— 

" 1. Where, from the history of the woman's previous confinement, we are led to 
suspect the existence of deficiency of space in the hard passages. Thus, if there 
had been considerable difficulty in each of her former labours, and that the children 
were dead born, or only the females born alive, these circumstances would afford 
tolerably certain evidence of the capacity of the pelvis being defective; and we 
believe it to be incontestable that this constitutes one of the most frequent predis- 
posing causes of rupture of the uterus." 

" 2 A fixed local pain existing in the uterus for any length of time, during preg- 
nancy and up to the time of labour, should be viewed with apprehension, as it 
No. XXXI.— July, 1848. 10 



142 



Reviews. 



[July 



may have been caused by some disorganizing process in the uterine substance, 
which will dispose it to give way under ttie expulsive efforts of parturition. 

" 3. During labour, the symptoms lhat might justly lead one to fear the occur- 
rence of this accident, are. constant and violent uterine action after the lupture of 
the membranes and discharge of the liquor amnS, without any corresponding im- 
pression being made on the "fatal head." 

Cl 4. The occurrence of a crampy pain in some part of the lower belly." 

u 5. Cramps in the legs very generally accompany the violent uterine action 
before spoken of, and, along with other symptoms, are to be esteemed premoni- 
tory of the accident in question." 

In the cases of threatened rupture of the uterus, that have come under 
the notice of our authors in the hospital, the object diligently aimed at was 
to moderate the inordinate violence of the uterine contractions, or to arrest 
them altogether, in the hope that they would return with less violence and 
more regularly. With this intention, a full bleeding was taken from the 
arm, — unless something was present to contraindicate it, — whilst the patient 
was in the erect position, and afterwards a tolerably large opiate was ad- 
ministered by the mouth, or, if this failed, an opiate enema or suppository 
was given. 

" Before resorting to the employment of these remedies, tarlar emetic solution was 
sometimes exhibited, as it very generally has the effect of diminishing the severity 
of the pains. By these means any degree of spasm will be removed, and the 
uterus may be brought to act in a more regular and normal manner; this will 
afford nature the fairest opportunity for surmounting the obstacle, and, at all events, 
will defer the period for resorting to instrumental delivery. Both experience and 
analogy lead us to believe that some of the muscular bands of which the uterus 
is composed, may be effected with severe spasmodic contraction, sufficient even 
to occasion laceration. Hence, the removal of such a condition is an object of no 
small importance." 

The remarks of the authors on the treatment of cases in which a rupture 
of the uterus has taken place, are judicious, but present nothing peculiar or 
particularly interesting. The delivery of the child and secundines as 
speedily and gently as possible, is the first great object to be accomplished ; 
this may be effected, in many cases, by the introduction of the hand and 
turning: delivery by the forceps can, our authors conceive, be very rarely 
eligible in cases of ruptured uterus, if it be true, as they remark, that the 
child dies very soon after the accident, and that the pelvis is generally 
under-sized in these cases. The Csesarian operation they consider so very 
rarely necessary, as not to require that it should be particularly noticed. In 
the immense majority of cases, therefore, where the head does not recede 
after the rupture has taken place, delivery is to be effected by the perforator 
and crotchet. 

Nine cases of laceration of the uterus occurred in the hospital during the 
period embraced in our authors' report, all of w'hich terminated fatally. 
Two of the patients were delivered by the natural efforts; one by the for- 
ceps; two by the perforator and crotchet; and four by turning. In two of 
the cases where version had been performed, it was also necessary to per- 
forate the head befdre it could be brought through the pelvis. In one 
instance the head presented; in two the face was towards the pelvis; and 
in all the others the vertex was the presenting part. Eight of the children 
were boys, all born dead, and one of them putrid; one child, a girl, was 
born alive. In four cases the accident occurred before the patients were 
brought to the hospital. One of the patients died in nine hours after the 
accident; one in fifteen, and one in sixteen hours; — two died on the 



1848.] 



Practical Observations on Midwifery. 



143 



second day; two on the third day ; one on the fourth day; and one on the 
fifth day. 

A detail is given' of each of the nine cases. 

The observations on plural births follow in order. From these we 
extract the following remarks, in reference to the management of twin 
cases ; we believe the practice pointed out to be a judicious one. 

"The rules of practice that have been followed in the management of twin 
cases, we shall now briefly detail, After the birth and separation of the first child, 
the binder is applied with a moderate degree of tightness. A vaginal examina- 
tion is then made, and if the second foetus be found presenting favourably — that is, 
with the head or lower extremities — its membranes are forthwith ruptured. This 
is a slight deviation from the practice usually laid down by authors: but Dr. John- 
son is of opinion that it is better to let off the liquor amnii at once than to wait 
any time before doing so; and we certainly think that this measure tends to pro- 
duce a firmer and more permanent contraction of the uterus subsequently. Great 
faintness or exhaustion of the patient might render some delay advisable; but 
such a condition has very rarely occurred at this period. Should any part of the 
upper extremity of the second child present, the operation of turning ought to be 
undertaken immediately, before the pains have time to be renewed, or to have 
acquired much strength. If good uterine action did not come on within forty 
minutes or an hour after the rupture of the membranes, a stimulating injection 
was thrown up the rectum, and this, with a little friction over the uterus, seldom 
failed to increase the energy of the pains." 

The authors state it as their conviction that, by steadily following these 
rules, the operation of turning, when the vertex of the second child presents, 
will very rarely be necessary, unless on account of some untoward com- 
plication. 

The next subject to which the observations of our authors refer, is that 
of Funis presentations. The directions for their management are marked 
with good sense; we cannot spare room for any account of the plan pro- 
posed by the authors for the reposition of the prolapsed funis. 

The two remaining sections treat, the one of ophthalmia neonatorum, and 
the other of the proper management of still-born children. The observa- 
tions contained in both are excellent and of a strictly practical character; 
but tile length to which we have already extended this review precludes 
our noticing them more fully. 

In concluding, it is scarcely necessary to say that our estimate of the 
work of Drs. McClintock and Hardy is a very favourable one. Upon all 
the leading subjects connected with the practice of obstetrics, it presents a 
series of observations particularly interesting, because derived from direct 
clinical sources, sufficiently extensive and favourable for arriving at correct 
conclusions. We return our thanks to the authors for having thus pre- 
sented to us the results of the practice of the Dublin Lying-in Hospital. 
Had they woven these into a formal systematic treatise on midwifery, they 
might perhaps have gained for themselves more eclat, but we doubt very 
much whether they would have conferred as much benefit upon the pro- 
fession : we would sincerely desire that the medical jnmates of all our pub- 
lic institutions could be induced to present the results of the observations 
there collected, and the practice there pursued, in the same unpretending 
form as that adopted in the work before us. D. F. C. 



144 [July 



BIBLIOGRAPHICAL NOTICES. 



Art. XII. — Principles of Medicine : comprising General Pathology and Therapeutics, 
and a brief general view of Etiology. Nosology , Semeiology, Diagnosis, Prognosis, 
and Hygienics. By Charles J B. Williams, M. D., F. R. S,, Professor of the 
Principles and Practice of Medicine, and of Clinical Medicine, and First Phy- 
sician to the Hospital, University College, London, &c. &c. Second Edition, 
considerably enlarged. London, 1848: 8vo. pp. 533. 

Dr. Williams tells us in his preface that " more than a year has elapsed since 
the first edition of this work was out of print." The same we believe to be true 
of the two editions through which the work has already passed in this country. The 
present edition contains very extensive additions, comprising the enunciation 
and application of most of the facts and established deductions made available to 
the science and art of medicine during the last few years. These additions per- 
vade almost every portion of the work j but they preponderate in the following 
subjects: — 

" In Etiology, mechanical, chemical, and dietetic causes of disease, defective cleanli- 
ness, ventilation, and drainage. In Pathology, the tabular views of the elements of 
disease; reflex action and sympathy; elementary changes in the blood; congestion; 
determination of blood ; inflammation, in its nature, manifold results and modes of 
treatment; degeneration of textures ; cacoplastic and aplastic deposits, and their treat- 
ment, with a notice of the action of the cod liver oil ; and the whole chapter on 
Hygienics, comprising food, clothing, air, temperature, exercise, mental occupation, 
sleep, and excretion.'' 1 — p. vii. 

In endeavouring to adapt the work to the rapid improvements in medical science, 
in very few instances has the auihor found it necessary to retract or supersede the 
inferences and views set forth in the first edition. On many subjects they have 
been confirmed and extended by recent researches to a degree which has not less 
surprised than convinced him of their truth. When these views were opposed to 
those generally held, Dr. Williams was led to test them more severely by all the 
experiments which physiology, clinical observation, and pathological research 
could supply. The result has been a firmer and clearer conviction of their sub- 
stantial truth. The reason given by Dr. Williams in his preface to the first edition 
of his work, for its publication, still obtains, namely — u that there is no work [in 
the English language] which fully treats of the subject of General Pathology, and 
its application to practical medicine. With many excellent and 

elaborate treatises on the details of medicine, we have scarcely any that treat of 
those general principles in the nature and treatment of diseases, which are really 
fundamental in the practice of medicine " There is much truth in the following 
observations of the author: — 

u It seems quite extraordinary that, notwithstanding the recent rapid improve- 
ments and comparative perfections of the contributory sciences, practical 
medicine should still halt in the domain of empiricism. A chief reason for the 
anomaly seems to be, that science and practice have been rarely pursued by the 
same parties. Scientific men are not and cannot be practical, because they have 
had no experience: and practitioners know little of science, and therefore derive 
little good from it. Instead of working together, these parties are at issue with 
each other. But it is high time to put an end to this feud. Philosophers must 
descend from their transcendental positions, to consider details of practice and 
purposes of utility. Those who would be practitioners must gain from science 
that knowledge and that method which render experience instructive and useful.' 7 
—p. x. 

The proper foundation of medical studies, the only basis of practical medicine, 



1848.] 



Williams' Principles of Medicine. 



145 



is general pathology ; and Dr. Williams thinks, and justly so in our opinion, "that 
a chief reason why the practice of medicine has been commonly so distasteful, 
and so difficult in its- study, and so unsatisfactory when tested at the bed side, is, 
because its foundation, general pathology, has not been efficiently taught." It is 
the connecting link between practical medicine and anatomy and physiology. 
Sound principles of medicine are the u embodiment of the results of experience in 
disease, with a knowledge of structure and function in health. 

li The great proof of the practical utility of general pathology is. the aid which 
it gives in the study of clinical medicine, and the light which clinical medicine 
continually throws on it. The states which the practitioner has to treat are often 
too indefinite or too mixed to correspond with any of the definitions of special 
disease. They frequently consist of functional disorder, varying with time and 
circumstance, or changing its place, so as to present no fixed characters. But, 
compared by the pathologist with the standard of health, and analyzed from their 
complexity, their nature becomes intelligible, and their proper treatment obvious, 
so far as means are possessed to counteract or control that which is wrong." — p. 
524. 

Practitioners act more on general ideas of disease than on their knowledge of 
particular diseases. 

" They feel the pulse and the skin, to guide them in the use of blood-letting, 
whether they have found out the special disease or not. They examine the tongue, 
and inquire as to the state of the evacuations, to guide them in the use of purga- 
tives, under whatever complaint the patient labours. They consider the com- 
plexion and bodily strength in connection with dietetic measures; and the chief 
treatment of convalescence depends on rules suggested by general pathological 
knowledge." — p. 525. 

u Throughout our examination of the details of disease, we shall find the prin- 
ciples of general pathology continually exemplified; and through these principles 
the mind can master the details to an extent wholly unattainable by those who 
pursue them as unconnected matters of fact. Those who begin the study of prac- 
tical medicine by attempting to learn the details of diseases, are like those who 
would endeavour to master all the facts of chemistry without any knowledge of 
the general facts or laws of chemical action, affinity, and definite proportions: 
yet even in practical chemistry, or chemistry applied to the arts and manufactures, 
the most extensive and important services have been obtained from these very 
principles, applied to the details." — p. 529. 

Participating fully in these views, we shall now enter into a somewhat detailed 
examination of Dr. Williams' " Principles," and permit our readers to judge of 
the manner in which he has acquitted himself of his important and, as w r e think, 
difficult task. 

Chapter first treats of etiology, or the causes of disease. Dr. Williams discards 
the lev m proximate cause — used by Cullen, after Gaubius — as representing properly 
the pathological condition, and being rather a part of the disease than a cause: and 
he divides the remote into predisponent and exciting causes. He includes under the 
first head, the following: — '1, debilitating influences; 2, excitement; 3, previous 
disease: 4, present disease; 5, hereditary constitution : 6, Temperament : 7. age; 
8. sex; 9, occupation. The different subjects are cleverly, though succinctly, 
handled. The exciting causes are subdivided into cognizable and non-cognizable. 
The first comprise mechanical and chemical causes; ingesta; violent exertion ; 
mental emotion; excessive evacuation; retention, suppression, and diminution of 
evacuations ; defective cleanliness, ventilation, and drainage; temperature, and 
changes: the second, the endemic, epidemic, and infectious causes of disease, 
whose existence can only be inferred, and not proved. Our authors' views on 
these vexed questions are moderate, and will commend themselves to the reader. 

Chapter second is devoted to pathogeny or pathology proper. As this subject 
occupies the greater part of the work, and possesses some claims to originality, it 
will be the chief object of our analysis. The aim and purpose of this portion of the 
book are thus explained: — 

li Disease is a change from the natural condition of the function or structure of 
the body; but the change is generally more or less compound, involving several 
elementary functions or structures; and it is obvious that we cannot obtain an 



146 



f 

Bibliographical Notices. . [July 



accurate knowledge of the nature of disease until we have ascertained that of its 
component parts. As the anatomist and the physiologist examine structures and 
functions by separating or analyzing them into their constituent parts, before he 
contemplates them in combination, so should the pathologist study these constitu- 
ent parts, or elements, in disease, before he can understand their combinations* 

" The chemist, in the examination of his subjects, finds that there are some 
principles or elements that cannot be analyzed or divided further; these he calls 
ultimate or primary elements: others, again, are simple compounds, which may 
be analyzed: but they occur so constantly, and act so singly in compounding and 
giving properties to complex matter, that they are called proximate principles or 
secondary elements. A parallel case might be shown of physical science. 

" So it should be with physiology and pathology. There are the healthy and 
diseased primary or ultimate elements of structure — muscular fibre, nervous matter, 
vascular fibre, and the elementary tissues of membranes, glands, skin, and other 
parts; and there are primary elements, healthy and diseased, of function of these 
same structures — irritability, tonicity, nervous properties, to which maybe added, 
because at present we cannot analyze it, the power of secretion and nutrition^ and 
lastly, the constituents of the blood. And there are the secondary or proximate ele- 
ments of disease, composed of the preceding primary elements, but still simple in 
comparison with the complex conditions of disease which they combine to pro- 
duce. 

•'' The varieties of disease affecting these several elements may be compre- 
hended under the heads of degree and kind ; degree, including excels and defect, or 
alterations of plus and minus: and kind, relating to changes not comprised un- 
der these heads, but otherwise expressed by the term perversion. By applying 
these heads to the elements of structure and function, we obtain a simple and 
comprehensive classification, which embraces all the important topics of general 
pathology/' — pp. 67-8. 

" These primary and secondary elements of disease are the especial subjects of 
general pathology. By the study of them we become acquainted with the mate- 
rials of disease, and their relations to each other; we learn how special diseases 
arise, and of what they consist: how they produce their phenomena and effects, 
how they are to be known, distinguished, and classified. Out of such a know- 
ledge, where it is correct, sufficient, and combined with an ample acquaintance 
with the properties of remedial agents, arises the rational method of relieving, 
curing, and preventing disease, the great ends of the art of medicine. 

"I readily admit that our knowledge of these elements or principles in patho- 
logy, is as yet too limited to be entitled' to rank as a complete science ; but I think 
that the attempt to describe and illustrate them will be useful, not only by making 
available all that is known on the subject, but also by showing what is not known, 
and needs investigation: thus suggesting fit subjects for further research." — pp. 
69-70. 

Under Ihe head of functional or dynamic diseases, the first of the primary ele- 
ments noticed is muscular irritability. This may be excessive, constituting spasm, 
or convulsion ; or it may be defective. 

Section second treats of tonicity. Our author defines this property of all mus- 
cular structures, and of some which are hardly accounted muscular, as "a tend- 
ency to slow, moderate contraction, not essentially terminating in relaxation;" 
and keeping "the parts in which it resides in a certain degree of tension." 

"This tone keeps muscles and limbs in their places when at rest, and out of 
their places when dislocated: if one set of muscles is paralyzed, the tone of their 
antagonists draws the parts in an opposite direction, as we see in paralysis of the 
porlio dura on one side of the face. A similar property is possessed by the intes- 

* "A begleet of this precept has greatly retarded the advancement — nay, even the 
formation — of pathological science. Men have begun with the very complex problems 
of inflammation and fever, before they have made themselves acquainted with the ele- 
mentary properties of textures, or even of vessels. The result has been, that the most 
profound reasoning and ingenious speculations have been wasted on nonentities, such as 
.spasm of the extreme vessels, increased action of the capillaries, &c. : and even observa- 
tion has been confused by the complexity of the subjects brought under it." 



1848.] 



Williams' Principles of Medicine. 



147 



linal tube, the urinary bladder, the air tubes, and the middle coat of the arteries, 
and gives ihem. a constant tendency to contract on their contents. In these, but 
particularly in the arteries, it performs an important part, both in health and in 
disease. By this the arteries contract, when they cease to receive blood from the 
heart, and thus are found empty after death. It adapts them to different decrees 
of fulness, yet maintains in their walls a certain tension favourable to equality in 
the motion of the blood.' 7 — p. 74. 

The distinct property of tonicity and irritability has been asserted, and it is said 
that though irritable fibres possess tone, tonic textures are not irritable. 

"This," says Dr. Williams, ' : is not true with regard to the arteries; for 1 have 
many times distinctly seen them slowly contract, and remain contracted, at a 
point to which an irritant, mechanical, chemical, or electric, has been applied. 
The late discovery, by Henle. of a structure distinctly muscular in arteries, confirms 
this observation. 1 have proved, in like manner, the irritability of the air tubes, 
which move more rapidly under a stimulus than the arteries; whilst that of the 
intestines is still higher in decree, but still inferior to that of the oesophagus and 
voluntary muscles, the contractions of which, on the application of a stimulus, are 
abrupt, and immediately followed by relaxation. So far. then, it appears, that 
tonicity is influenced by the same agents which excite irritability: but another 
agent, temperature, seems to affect them differently. Cold increases tonicity and 
impairs irritability. Under the influence of cold, vessels generally, but especially 
arteries, shrink in size very remarkably; and the muscles and other textures pre- 
sent a firmness and contraction which impede the quickness of motion character- 
izing the highest degrees of irritability. Under the influence of heat, on the other 
hand, although muscles are relaxed, they are more irritable, and the pulsations of 
the heart are more frequent. 

" Cold and heat, therefore, become the best tests for tonicity; and by their means 
we find this property to be possessed by textures which are not distinctly muscu- 
lar; I mean, the veins and the cutis, which in a remarkable degree contract with 
cold, and become relaxed with heat/ 7 — pp. 75-76. 

Tonicity is an important property in the animal economy, the preservation of 
health often depending on its integrity, its modifications being peculiarly felt in 
the vascular system. 

/'Practical men have long admitted the existence of something of this kind, 
without defining or localizing it ; and the terms tone and atony, bracing and relax- 
ation, tonic and relaxing remedies, become quite v appropriate in connection with 
this property.' 5 — p. 76. 

Excessive tonicity is caused by an over-nourishing and stimulating regimen, with 
insufficient exercise; a dry bracing air; tonic medicines; the excitement of fever, 
&c. In inflammatory fever, excessive tone of the vascular system is a chief con- 
stituent. The remedial measures are those which relax the tonic fibre, and increase 
the secretions, as warm bathing, exercise, sudorifics, aperients, diuretics, and mo- 
derate diet, with probably antimony. 

In defective tonicity, the muscles are flabby, and incapable of continued exertion, 
though sometimes irritable, w T ith the tremulousness of debility. The heart is irri- 
table, and easily excited to palpitation; the pulse soft and yielding: "it-may be 
full when slow, and sharp when frequent; but it is without firmness or endurance 
and is easily accelerated. Another distinctive character is its retardation, increas- 
ing the interval between the heart's beat and distant pulses ; so that the radial pulse 
is ofien felt after the second sound of the heart is heard ; the tubes being less tense, 
the pulse-wave is slower than usual. Sometimes the absence of that tightening 
of the walls of the arteries by which the tonic fibres control their movements, per- 
mits their mechanical elasticity to come into play, and this reacting after each 
stroke of the" heart gives that peculiar reduplication or rebounding of the pulse, 
which has long been described under the term dichrotous pulse. This is often ob- 
served in convalescence from fevers and other diseases after the subsidence of 
vascular excitement. A loose relaxed state of the vessels renders the circulation 
in distant parts weak, so that the extremities are cold, whilst the head and internal 
organs may be congested. Sudden exertion or change of posture may disturb the 
circulation and cause faintness or giddiness. Want of tone also in the stomach 
and intestines causes indigestion and costiveness, and permits them to become 



148 



Bib lio graphical Notices . 



[July- 



distended with wind and accumulating feces. The secreting organs, irregularly 
supplied with blood, are also liable to disorder ; being either scanty, depraved, or 
profuse and watery.' 5 — pp. 77-78. 

In individuals with the system in such a state of atony, there is decided pro- 
clivity to certain diseases. There is no power to resist depressing agents, as 
malaria,- infection, &c. On exposure to cold, the blood is quickly driven from the 
surface to the internal organs, causing congestion and inflammation. 

" The proper remedies for defective tonicity are tonics, which are agents that 
tend to increase the tone of the whole system, particularly of its muscular and 
vascular parts. We have already stated that cold has this effect in a marked de- 
gree, and in truth, cold, properly applied, is one of the best tonics which we pos- 
sess. For this purpose its application should be sudden and too brief to cause 
depression or any of its morbid effects. The shower-bath and plunge-bath are the 
most effectual forms: and free sponging, with cold salt water, is applicable even 
to weak subjects. A pure bracing air and much exposure to it, with moderate 
exercise, have also useful tonic effects. There are many medicinal tonics, the 
most effectual of which are bark and its preparations, medicines containing iron, 
and the mineral acids. Generous living may be considered a part of a tonic plan, 
in so far as it tends to enrich the blood, which sustains tonicity as well as all other 
vital properties.'" 7 — pp. 78-79. 

In the third seciion, on diseased sensibility, Dr. Williams holds this language: 

"An anodyne influence more powerful in degree, than that induced by any 
other agent, although transient in duration, is that resulting from the inhalation of 
the vapour of sulphuric ether, which has during the last year been extensively used, 
first m America, and subsequently in this country. The operation of this agent, 
and of nitrous oxide gas (which has a similar effect), is on the sensorium, rather 
than merely on the sensitive nerves. In most instances, if continued for a suffi- 
cient time, it induces complete insensibility, so that the subject may undergo the 
most severe surgical operation, and a female may go through the process of par- 
turition, without suffering any pain. In many cases, however, especially where 
the inhalation has been less prolonged, or less impregnated with ether, sensibility 
is blunted, but not destroyed, and the patient makes movements and may utter 
expressions indicative of slight pain, yet has no recollection of it when restored to 
consciousness. The memory seems to be more affected than the perceptive func- 
tion. The power of voluntary motion is suspended in about the same ratio as 
sensibility : but the reflex motions of the eyelids, breathing, &c, are lowered but 
riot abolished, unless the inhalation be continued so long as to induce complete 
asphyxia. 

"The operation of ether vapour is obviously uarcotic, like that of opium and 
alcohol; and is more speedy and transient, because it passes freely and directly 
through the lungs into the arterial blood and affects the brain, and is as promptly 
dispersed by its diffusion throughput the body. It has been maintained by many, 
that it operates by its interference with the respiration, inducing a degree of as- 
phyxia; but so far is this from being the case, that its best effects are produced 
when the respiration is steadily maintained ; and it has always appeared tome 
that the end to be aimed at in the administration of ether-vapour, is to narcotize, 
as far as possible, without too much embarrassing the breathing. This is difficult 
to accomplish without a freer supply of oxygen than atmospheric air contains; and 
I should expect safer and more satisfactory results from the inhalation of a mixture 
of eiher-vapour with oxygen gas, which might be continued with safety for a much 
longer period than with the vapour and air only. 

"Although the chief influence of etherization is transient, yet by saving the 
nervous system from the shock of intense temporary pain during an operation or 
paroxysm of suffering, it often prevents that consequent nervous irritation and ex- 
haustion which is as injurious to the vital powers, and which favours the return of 
the painful attack. Thus in neuralgic and painful spasmodic affections, the re- 
moval of one or more paroxysms by etherization may break the habit of diseased 
action, and effect a permanent cure." — pp. 81-82. 

Sections fourth and fifth are on diseased voluntary action, and the diseases of 
reflex and sympathetic nervous influence. Though short they are highly instruct- 



1848.] 



Williams' Principles of Medicine. 



149 



ive, and exhibit the thorough and correct knowledge of the author of the physio- 
logy of the nervous system. 

In the sixth section on secretion, Dr. Williams sa}~s : 

11 1 have for the last twenty years* advocated the opinion recently advanced by 
Dumas and Liebig, that the formation of the principles of the chief secretions 
takes place through chemical affinities, especially those of the absorbed oxygen 
and the constituents of the blood, controlled by vital agencies; but this view leaves 
still as a vital property the power which the liver has to separate bile; the kidneys, 
urine; mucous membranes, mucus, &c. 

u We are thus led to consider secretion as a peculiar properly of the secernent 
structures, just as irritability is of muscular fibre ; and as such its disorder constitutes 
a primary element of disease. In doing this we avoid the hypothesis of some 
physiologists, who ascribe secretion to nervous influence, a notion by no means 
accordant with numerous facts. 5 ' — pp. 100-1. 

The influence of the blood — the material from which the secreted matter is 
supplied — on the quantity and quality oi the product, as well as that of the nervous 
system, are mentioned as important elements in derangement of the process. The 
effects of excessive secretion are both forwards and backwards. 

''The forward effects of an excessive secretion of bile depend on its stimulating 
properties. It irritates the intestinal tube, causing a bilious diarrhcea or cholera. 
The symptoms of this consist in an exaggeration of those propeities of the ali- 
mentary canal which have already been described as elements of disease. Thus 
the bile irritating causes increased irritability, and more rapid motion of the matter 
through the tube: pain from exalted sensibility : vomiting, straining, and cramps, 
from exalted excitomotory function ; profuse mucous secretion from excited secer- 
nent function."' 

" But excessive secretion may also have effects bachicards, on the organs, and 
on the blood from which it proceeds. Excessive secretion often weakens the vital 
properties of the organ, so that, in its proper function, it subsequently becomes 
torpid. Thus after diarrhcea the bowels often become torpid from defective secre- 
tion. So. too, in cases where an excessive secretion continues for a long time, it 
generally is impaired in its quality from a similar cause. 

u Excessive secretions, if abounding in animal matter, may not only reduce the 
mass of the blood, but also affect its composition. Thus bile and urine, which 
differ much in composition from the blood, if separated in unusual proportions, 
must leave the blood modified. Urine contains a great preponderance of azote; 
and its excessive formation from the principles of the blood would leave a pre- 
dominance of hydrogen and carbon in this fluid. The bile, again, abounds in 
hydrocarbon, the copious removal of which would leave a superfluity of azote. 
It maybe objected to.this statement, that according to the opinion of some chemists, 
the urine and the bile are not formed from the constant elements of the blood, but 
from materials derived from the food, and from the decay or transformation of the 
tissues. To this it may be replied, that this opinion is at present no more than 
hypothetical ; and should it prove to be true, it would not affect the undoubted fact, 
that the secretions of the liver and of the kidneys are intended to balance one 
another, and the removal of carbon from the lungs: and that whether the materials 
from which these eliminating processes are supplied be the principles of the blood 
itself, or the decayed constituents of tissues, or matters derived from the food, the 
co-operation of all these processes will be generally required to maintain a uni- 
formity in the composition of the circulating fluid; so, too. if one of these pro- 
cesses is more active than the others, the blood must suffer by the excess of those 
matters which the less active processes allow to accumulate in it. A clinical illus- 
tration of this position may be found in cases of bilious diarrhcea or cholera. This 
flux of bile is either accompanied by a highly loaded state of the urine, or by 
fever; in the latter case,'" the fever does not subside until the mine becomes very 
copious, or deposits an abundant sediment. The most probable interpretation of 
this fact is, that the excessive secretion of bile disorders the composition of the 
blood; so long as the kidneys rectify this disorder by separating, in greater abund- 

* In a thesis. De sanguine ej usque mutationibus, Edin. 1824. See also Med. Gaz., 
September and October, 1835. 



150 



Bibliographical Notices. 



[July 



ance, the solid contents of the urine, no fever results; but if the kidneys fail in this 
task, fever ensues, and continues until they accomplish it ; then a free secretion, 
and copious deposit is symptomatic of the decline of the fever." —pp. 102-3. 

The* morbid effects of defective secretion may be, also, both forwards, on the 
parts for which the secretion is intended, and backwards, on the organ and on the 
blood from which it should be eliminated. 

The most remarkable of the backward effects of defective secretion are in- 
stanced in case of the excretions. The distinctive materials of the secretions of 
urine and bile appear to be positively noxious, and poison the "System if not 
separated from the blood. Thus the sudden suppression of urine or bile causes 
typhoid symptoms, extreme depression, and coma, which speedily end in death; 
and, in such cases, urea, or the colouring matter of the bile, has been found in 
various organs. Where the suppression is incomplete, the poisoning process is 
more tartly; various functional and visceral derangements are produced, such as 
delirium or lethargy, dyspnoea, palpitation, vomiting, diarrhoea, dropsical effusions, 
structural degenerations. &c, which always cause injurious effects, if the defective 
excretion be not restored. But the amount of these effects will depend on the 
extent, and especially on the suddenness of the diminution of the excretion: and 
it is very remarkable when it is very gradual how little disturbance it may for 
some time induce. In these gradual cases, still more remarkably than in those 
of more sudden suppression, some of the excrementitious matters may be delected 
in the blood and in other fluids and solids of the body. Thus in some structural 
diseases of the liver, the colour of the bile becomes manifest, first in a yellow, 
and by accumulating, in a deep greenish colour in all the textures, constituting 
the yellow and the black jaundice. In granular degeneration of the kidneys, in 
which scarcely any urea is excreted by these glands, this principle is found in the 
blood and various fluids of the body. In the case of a patient of mine affected 
with ascites from disease of the heart, liver, and kidneys, Mr. Garrod obtained 
nearly four grains of nitrate of the urea from an ounce of the peritoneal fluid, and 
a considerable quantity of bright yellow solid matter, probably bilious. In other 
cases I have known the fluid of ascites and anasarca from diseased kidneys emit 
a decidedly urinous smell, and exhibit on analysis easily appreciable quantities of 
urea. One of my pupils, Mr. Palmer, detected urea in the serum contained in 
the ventricles of the brain, in a case of fatal apoplexy from granular kidneys and 
diseased heart." — pp. 106-7. 

In idiopathic fevers, the excretions are frequently defective, and many of the 
constitutional symptoms in this class of diseases are no doubt due to this cause. 
During the Edinburgh epidemic of 1813, crystals of the nitrate of urea were 
obtained from the serum of the brain, and from the blood, in several cases, by Dr. 
Henderson and Mr. M. W. Taylor. 

L - There can be little doubt that a morbid element, which in its extremes acts 
so injuriously as to cause serious disorder, and even speedy death, must in slighter 
degrees be an important cause and constituent of disease : and I believe that gout, 
rheumatism, and many cachectic states leading to diseases of nutrition, degenera- 
tions, dropsies, &c, are essentially connected with defective excretion."' — p. 107. 

In speaking of the special stimulants of the secreting organs, it is properly ob- 
served, that, " if used in excess, or too long, may not only cause general weakness, 
but also exhaust the vital properties which they excite; and the result may be a 
diminution either of the secreted fluid, or of its most characteris'.ic constituents. 
Hence the long or excessive use of mercury causes torpidity of the liver; that of 
purgatives, imperfect action of the bowels; that of diuretics, scanty urine, or 
albuminous or watery urine, defective in urea. These facts point out the expedi- 
ency of intermitting the use of these agents, and of alternating or conjoining them 
with others calculated to improve the vital properties of the textures generally, 
which may often be effected by the medicines called tonic, and by regimenal 
means which improve and equalize the stale of the circulation, and preserve the 
digestive and assimilative functions in the best order. In illustration of this posi- 
tion, I may refer to the acknowledged advantage of giving bitters with or after 
mercurial courses; chalybeates with or after saline aperients and diuretics, when 
these are long used; and these additions, which alone, or used at first, would 
check the secretion to be increased, now sustain it and render it permanent. Some 



1848.] 



Williams' Principles of Medicine, 



151 



medicines which are inferior in efficacy to ihose already named, are yet, in some 
instances, more eligible for chronic cases of defective secretion ; because they are 
less exhausting, and. combine some measure of tonic influence with that of in- 
creasing the secretions. As examples of this kind may be named taraxacum, pre- 
parations of iodine, sarsapariila, nitric and nitro-muriatic acids. Courses of these 
medicines are sometimes of great efiicacy in keeping free the secretions after they 
have been restored by more powerful means; and they likewise often improve 
the functions of digestion and nutrition.'' — pp. 108-9. 

The diseases of the constituents of the blood is begun in the seventh section, 
and continued through the eight remaining ones of the chapter. These sections 
are amongst the most important and valuable in the work, and we especially recom- 
mend them to the reader. They are admirably executed. The subject is fully 
through concisely treated. 

Treating of the morbid changes of the blood, Dr. W. observes: 

" These, like those of the solids, may be often traced to individual elements, of 
which the blood is composed, the changes of which must be viewed as ultimate 
elements of disease, and are therefore properly included in the present division. 
But as the blood also operates as a whole, compound indeed in itself, but simple 
in its influence on vital functions and structures, it forms a proper connecting link 
between ultimate and proximate elements of disease. So, also, inasmuch as it is, 
in some respects, an organized compound, the materials of which are changed, 
together with its functions, and contributes to the production of change of structure 
in the solids of the body, the consideration of its changes will be a proper intro- 
duction to that of alterations in the circulation, which induce changes of structure, 
and thus lead to structural diseases themselves." — p. 111. 

The properties of the circulating fluid are first examined with reference to those 
which are most elementary, or to its respective constituents. " We have, life n, 
to consider — 



1. The red particles, 

2. Fibrin and colourless globules, 

3. Albumen and other dissolved animal 
matters, 

4. Oil, 

5. Salts, 

6. Water, J 



in excess, defect, and alteration." 



In speaking of the alterations in the colour, shape and size of the red corpuscles 
in connection with the medium, Dr. \V. says : 

i: It is highly probable that similar changes may take place in the living body, 
from circumstances which greatly alter the proportion of saline matter and water 
in the blood. May such change contribute to produce the serious symptoms, and 
even sudden death, which have ensued on drinking a large quantity of waier after 
great exertion? Has it aught to do with the reaction and irregular excitement 
sometimes occurring after excessive losses of blood ? Or with the symptoms of 
suffering which animals manifest at the instant of injecting water into their veins'? 
Dr. Owen Rees has suggested that the remarkable diminution of the blood discs 
in cases of albuminuria may be due to their destruction in consequence of the 
draining away of albumen from the blood, and thus reducing it to a very watery 
stale; and the same circumstance may prevent their development from the chyle 
and lymph, both in these cases, and in chlorosis. In several cases of Blight's dis- 
ease of the kidney I have observed the blood discs jau^ed or crenate at their 
margins, and otherwise imperfect; and the same remark has been made by Simon 
of Berlin and others, and by Andral in a case of chlorosis. In one fearfully rapid 
example of albuminuria, which proved fatal in six days, with effusion of pus in 
the joints the day before death. I found the colouring matter dissolved in the blood- 
liquor after death, and scarcely any red discs remaining. There were numerous 
pus globules in the blood. A similar total destruction of the blood di-cs\was ob- 
served in University College Hospital in the blood of a person who died of malig- 
nant scarlet fever with purpura. I have met with similar proofs of breaking up 
of the red particles, but to a much smaller extent, in acute purpura connected with 
jaundice, and in cases of disturbed function of the liver without jaundice; is this 



152 



Bibliographical Notices. 



[July 



due to the remarkable solvent power exercised by small proportions of bile on the 
red particles, noticed by Simon and others'?" — pp. 114-15. 

The same broken condition of the red corpuscles was noticed by M. Renzi, of 
Naples, in an epidemic typhus which prevailed in certain districts of Italy, in 1841, 
as well as in the Edinburgh epidemic fever before alluded to. 

The section on the changes of the blood from the transformation of chyle and 
of the textures, including the processes of nutrition and reparation, is particularly 
valuable from its suggestive character, and from the intrinsic importance of the 
subject Most pathologists now regard goutto depend on the accumulation in the 
system of an excess of lithic acid. This view, inferential previously, has recently 
been demonstrated to be correct, in the case of a patient of the author in whose 
blood lithic acid was detected. There was total absence of lithic acid in the urine, 
until during the exhibition of colchicum. when its characteristic crystals appeared 
under the microscope. The pathology of both gout and saccharine diabetes is 
admirably given, and we regret that we cannot transfer it to our pages. The treat- 
ment indicated is sound and discriminating. We have room only for the conclud- 
ing paragraphs. 

" in the effect which each exerts on the economy, there is a great difference 
between the morbid matter of gout and that of diabetes. The sugar in the latter 
has no tendency to accumulate in the system and produce local effects; but, acting 
as a powerful diuretic, it passes rapidly away, carrying with it a great quantity of 
water and of the other constituents of ordinary urine; and the thirst, dry skin, and 
emaciation of diabetes, seem to be chiefly due to this mode of operation. The 
common complication of diabetes with pulmonary consumption shows also, how- 
ever, that die plastic process is degraded. 

u The lithic acid of gout and gravel, on the other hand, has a tendency to accu- 
mulate in the body, and to cause the local and general irritations which have 
been already mentioned. Hence it becomes a chief indication to counteract its 
irritating properties, and to promote its elimination from the system. The medi- 
cines which are most efficacious in doing this are alkalies, or their carbonates, or 
their vegetable salts, with colchicum, or iodide of potassium, saline mineral 
waters, and alterative aperients. These all increase the action of the kidneys and 
intestinal canal, and drain off the offending matter from the system; but the ope- 
ration of colchicum is far more certain than that of the others: and its permanent 
efficacy depends on its continued action on the kidneys in particular." — pp. 
156-57. 

Chapter third is occupied with the consideration of the secondary or proximate 
elements of disease, consisting of two or more primary elements. u They com- 
prise, at least, three of the primary elements which have been considered — the 
blood and its constituents, the irritability and the tonicity of the organs concerned 
in its distribution." 

Ancemia is the first of these conditions treated of. The most common causes of 
general anaemia Dr. Williams considers to be irregularity of the menstrual function. 

It might seem difficult to understand," he observes. 11 how the last operates; 
but that in many cases it is a cause and not an effect of anaemia, is plain from the 
well-known fact that no signs of anaemia have occurred nntil cold, over-exertion, 
or mental excitement, or some circumstance, has suddenly checked the flow of 
the catamenia: it has not returned ; and then the patient begins to lose colour, and 
gradually to exhibit the anaemic state. In many cases I have kno wn this occur in 
young females who have previously suffered from acute rheumatism, implicating 
the heart. It would seem that in these cases some injury is done to the blood 
particles and to the powers by which they are repaired : this is manifest not only 
from the paliidity, but from the yellowish and almost greenish hue which the com- 
plexion sometimes presents, and which obviously depends on a discoloration of 
the textures by the altered blood, as in the neighbourhood of a bruised part. The 
nature of these changes has been already noticed. In some of these cases of 
chlorosis, the appetite is depraved ; there is such a complete disrelish for animal 
food and other nourishing articles, and such a craving for sour things, and even 
for matters destitute of nourishment, as chalk, cinders, &c, that it might be sup- 
posed that this perverted appetite is the cause of the anaemia, by deterring the 
patient from taking that food which is capable of making red blood; and undoubt- 



1848.] 



Williams' Principles of Medicine, 



153 



edly such an appetite, when indulged, must contribute to this result; but it is not 
so constantly present as to be considered the chief cause of the anaemia in the 
examples under consideration/*'— p. 163. 

Though the general symptoms of anaemia are those of weakness, still it is often 
accompanied by others of an opposite character, and which lead the inexperienced 
practitioner into error. Instead of depression there is irritation and exaltation of 
function, particularly in the nervous system. 

••Sensibility is sometimes acute; there is intolerance of light and sound, with 
flashes in the eyes, noise in the ears, a sense of rushing in the head, and vaiious? 
neuralgic pains. The excitomotory nerves are sometimes excited, and spasms or 
convulsive affections of different kinds may be present, or the organic functions 
may be affected, and palpitation, spasmodic asthma, vomiting and such sympa- 
thetic irritations, may occur. In a tew instances, anaemia has been a tended with 
delirium, or mental excitement bordering on it. 

" It thus appears that the functions which frequently are thus excited in the 
midst of general depression and weakness, are those of the nervous centres; and 
the generally nervous character of persons in a state of great weakness is con- 
nected with the same fact, so that nervousness and weakness are abnost synonymous 
terms. No explanation of this apparent anomaly has been to my knowledge pro- 
posed , but one seems to suggest itself in the peculiar distribution of the circulation 
through the nervous centres. When the mass of blood is reduced in quantity, the 
blood-vessels generally contract in proportion, their tonicity adapting them to the 
amount of their contents. But the vessels within ihe skull and spinal canal cannot 
contract vviih the same facility, for not being exposed to atmospheric pressure, and 
some of them being fixed in bony canals, they do not shrink as the blood becomes 
reduced, and therefore they retain more than their proper share of the circulating 
fluid* This disproportionate amount of blood in the nervous centres produces 
different effects, according to the degree in which the heart's propulsive power 
reaches it. Under the influence of temporary palpitation, fever, or other kind of 
excitement, the brain and spinal cord, through their uncontracted vessels which 
are among the nearest to the heart, receive an unusual share of its exalted but par- 
tial force; an erethism of some one or more of the functions of these nervous 
centres is the consequence ; and pain, spasm, sensorial excitement, intolerance of 
light and sound, or sympathetic irritations of some kind or another, occur. f In 
this condition the head may be hot and throbbing, the face flushed, the eyes suf- 
fused, whilst the extremities and the surface generally are comparatively blood- 
less, and either cold or very speedily becoming so on exposure. Epistaxis 
sometimes occurs, and although bringing momentary relief, may. if considerable, 
add to the evil, by increasing the anaemia." 5 — pp. 165, 6. 7. 

But the heart may be too enfeebled to propel onward the blood accumulated in 
the cerebral vessels, particularly the veins. Congestion of this organ is a neces- 
sary result; and we accordingly have - headache and giddiness, relieved by the 
recumbent posture, drowsiness, impaired mental faculties, obscured vision and 
hearing, partial paralysis, and, in extreme cases, coma or catalepsy." — p. 167. 

* This statement is not invalidated by the recent experiments of Dr. G. Burrows, 
(Med. Gaz , April, 1S43.) His experiments and expositions very satisfactorily demon- 
strate the absurdity of the notions, founded on Dr. Kellie*s paper, that the quantity of 
blood in the head is always the same ; but it remains clear that the circulation within 
the head and spinal canal, especially in man, is affected by losses of blood differently 
from the circulation in other parts. 

t Although the chief effect of excitement of the circulation in ana?mia is thus directed 
to the nervous centres, it is by no means confined to them. Other parts in the imme- 
diate vicinity of the heart become the seat of increased arterial pulsation and disturbance. 
Thus a painful throbbing is often complained of in the throat, chest, and epigastrium 
even when there is little pulse in distant arteries, and the extremities are cold. To 
understand these facts, we must bear in mind that when the arteries are full and tense, 
they oppose their fulness and tension to each contraction of the heart, which resistance 
reduces the strength of each pulse in the vicinity of the heart, although it continues to 
propagate it to a distance; but when the arteries are empty and loose, the heart squirts 
into them the blood in an unresisted jet, the force of which is strong near the heart, but 
extends not to distant arteries. 



154 



Bibliographical Notices. 



[July 



"This congestion may be only temporary, and lead to no serious results: hut 
in some cases I believe there occurs an event that has not been noticed by' 
pathologists— namely, a coagulation of the blood in the sinuses, and a consequent 
permanent obstruction to the passage of the blood through the brain. I have met 
with several cases more or less corresponding with tbe«following description. 

" A young female becomes ansemic, and after exhibiting various symptoms of 
feeble general circulation, with headache, drowsiness, and impaired sensorial 
functions',, suddenly becomes worse; passes into a state of stupor with dilated 
pupils, sometimes varied by slight manifestations of delirium, throbbing of the 
carotids, and partial heat, of the head, and dies comatose. On opening the head, 
a small quantity of serum is found under the arachnoid and in the ventricles, 
sometimes with a little lymph (in one case there was none). The vascularity of 
the membranes is remarkable, but the vessels most distended are the veins, and 
in the larger of these and in the longitudinal sinus, there is a firm coagulum. In 
parts, especially at the torcular Herophili, this coagulum blocks the whole sinus, 
and exhibits a separation of fibrin, portions of which are softened down into that 
opaque purilaginous matter which was long mistaken for pus, but which Mr. 
Gulliver has shown to be a mere disintegration of the fibrin which mere stagna- 
tion in a warm temperature may effect. These have been taken for cases of 
meningitis. No doubt inflammation may supervene in them occasionally, but in 
two cases that have fallen under my notice, there was no adhesion of the arach- 
noid nor deposit upon it. nor any other unequivocal mark of inflammatory action ; 
yet the fibrinous and bloody concretions in the veins and sinuses were most 
remarkable for their size and firmness."* — p. 167. 

We pass to the next division Hyperemia or Excess of Blood. Several conditions 
are included under this head. A view of these important proximate elements of 
disease is snven in the following table. 



' General= Plethora 

Hyper 




with motion increased— Sthenic \ 

— — diminished^ Asthenic / Results. 

I Hemorrhage. 

'with motion diminished^ Congestion 



blood, f Locals 



( Flux. 



— - — increased= Determination of blood ^■^ r0 I 1s 3 r ' 
partly increased, 



partly climinished=Inflammation. 

After treating of Plethora, sthenic and asthenic, Dr. Williams passes to the consi- 
deration of Congestion, or local hyperaemia, with diminished motion. We cannot 
now discuss the theoretical portion of this section, and though not disposed to give 
our unqualified assent to all the views of trie author on this subject ; still we regard 
them as generally sound. 

The symptoms and effects of Congestion are detailed with great clearness and 
precision, both as regards the local effects, and those on the sysiem at large. As 
a specimen, we extract the following regarding the pathology of Blight's disease: — • 

( -I have for several years referred albuminous urine to congestion of the kid- 
ney; and this view has been lately confirmed by some experiments by Mr. G. 
Robinson. The following considerations led me to entertain this opinion: — 1. 
The urine often becomes albuminous during great embarrassment of the circula- 
tion in cases of organic disease of the heart or lungs, when the kidneys are other- 
wise healthy. 2. I have in many instances observed temporary albuminuria 
during the cold stage of ague ; and the congestive stage of eruptive fevers. 3. In 

* A wax model of the sinuses and membranes in one of these cases is in the museum 
at the University College. Cruveilhier gives a representation of a similar case, which, 
without sufficient reason, he considers as one of cerebral phlebitis. Andral mentions a 
case of cerebral hemorrhage in connection with anaemia, which was probably of the 
same kind. 



1848.] 



Williams' Principles of Medicine. 



155 



granular degeneration of ihe kidney, the amount of albumen in the urine is aug- 
mented by circumstances causing congestion of the kidney, and is reduced by 
remedies suited to remove this. 4. The most common form of Bright's disease of 
the kidney in its earliest stage, presents the appearance of a highly congested 
structure, and is excited by causes calculated to produce congestion, such as fre- 
quent irritation of the kidneys by stimulating liquors — congestion from exhausted 
tone; continued exposure to cold, especially after the kidneys have been thus ex- 
cited—congestion from intropulsion ; scarlatina probably operates as the two last 
combined. 5. The albumen in the urine abounds most in the congestive (first) 
stage of Brigfht's disease — the vessels becoming more or less obstructed in the 
progress of the disease by a deposit of fibrin with granular cells in the tubules, 
and in some instances around them, which deposit at the same time perpetuates 
some degree of congestion, whilst it supersedes the proper secreting structure/' 
—p. 193. 

The remedies indicated for the treatment of congestion are judicious. 

Section fifth treats of local hyperemia, with increased motion, or determination 
of blood. There is nothing here that need detain us, though the section is an ad- 
mirable one. 

The results of hypersemia. as hemorrhage, flux and dropsy, occupy the succeed- 
ing seciion. It teaches right doctrine, and will be read with advantage. The 
soundness of the following remarks on the treatment of dropsy depending on vis- 
ceral disease, cannot be disputed. 

-The tendency of dropsy connected with diseased heart, kidneys, or liver, to 
recur again and again, and become chronic, renders it needful to vary as much as 
possible the remedies employed, as well as to use means to support the strength. 
It is an important point in the treatment of such cases not to exhaust the powers 
of any secreting organ by too long acting on it, and not to expend the efficacy of 
anyone remedy^by loo long continuing its use. By employing sometimes diu- 
retics, sometimes purgatives, sometimes diaphoretics, and by aiding each of 
these, by local depletion or derivants. or by stimulants and tonics, according to 
the temporary prevalence of vascular fulness and excitement, or the converse, 
much may often be effected to prolong life. It is in the application of these rules 
to the treatment of prolonged cases, that the skill and resources of the rational 
practitioner are most tried, and his superiority over the routinist is be>t proved. 
It is under these circumstances, too, advantageous to have at command a great 
variety of medicines, particularly diuretics, and to alternate them or Vary them in 
order to increase or maintain their effect. Those that 1 have found most effectual 
are — combinations of mercury, squill, digitalis, and conium (not in acute albumi- 
nuria) ; combinations of decoction of broom, or pyrola umbeliata, with nitrate and 
acetate of potass: the juice or extract of taraxacum, with the same salts or bitar- 
trate of po:ass, or with, nitric acid (particularly in hepatic disease) ; infusion or 
tincture of digitalis, with iodide of potassium, and bitartrate of potass (in diopsy 
after scarlatina)-; the same, together with increasing doses of tincture of cantha- 
rides (in asthenic cases of albuminuria, after cupping to the loins and hydragogue 
purgatives) ; ammouio-tartrate and araraonio citrate of iron in Seltzer water (in 
asthenic dropsy) ; gin in cream of taitar beverage (imperial) ; compound spirit 
of juniper, spirit of nitric ajther. with various others (in cases of debility). The 
latter stimulant diuretics have disappointed me more than any of the rest." — pp. 
241-242. 

The seventh section is the most elaborate in the work, both theoretically and 
practically : it is an exposition of the important subject of inflammation, in all 
its pha-es and varieties: a subject which has always attracted the first attention of 
the pa Ihologist. 

The pathological definition given by Dr. Williams to distinguish inflammation 
from the other varieties of hypeiOBmia is — '-'-too muck blood in a part, with motion 
(of that blood) partly increased, partly diminished." — p. 244. 

<; But besides this pathological definition, its outward characters may be briefly 
defined in the four signs which, from the time of Celsus, have been considered 
distiuc. five of inflammation, redness, heat, pain, and $welling. These signs are 
sometimes produced by congestion, and by determination of blood ; but in a de- 
gree less marked, and for a time less continued, than in inflammation; and 



156 



Bibliographical Notices. 



although there are cases and forms of inflammation in which it is not possible to 
detect all these marks, they may still be said 10 constitute its most general charac- 
ter. In common with other varieties of local hypersemia, inflammation owes the 
sign of redness to the excess of blood in the part, but we shall find that ibis redness 
is'heightened by a peculiar concentration of the particles in the inflamed vessels, 
which is also the cause of the peculiar results of the process. As in determination 
of blood, the heat and pain are in part due to the increased motion of the blood; 
but in inflammation, they are exaggerated by the motion being opposed 10 obstruc- 
tion. As with other forms of hypersemia, the swelling arises partly from the over- 
distension of the blood-vessels, and partly from effusions from them : but in these 
effusions, inflammation differs from congestion and simple determination, depart- 
ing still further than these from the natural quantity and quality of the effused 
matters/'— pp. 244-245. 

It has been the custom to refer the first movement of inflammation to the 
nerves. Dr. Williams adduces the following arguments to show that an im- 
pression on the nerves is not essentially a part cf the first process of inflamma- 
tion. 

1. Some of the causes of inflammation (the majority of those inducing internal 
inflammation) produce on the nerves or nervous system no known primary effect, 
which resembles that of other causes of inflammation (irritants) : thus, inflamma- 
tions excited by cold are often preceded by no marked nervous disturbance; 
whereas the strongest impressions of cold on this system are frequently not fol- 
lowed by inflammation. 2. Inflammations often originate in congestions, and in 
the sudden suppression of hemorrhages and other discharges, without the occur- 
rence of any symptoms referable to the nerves: hence inflammations thus arising 
may escape detection, and are called latent. 3. Persons in whom nervous pro- 
perties are most developed, are not those most susceptible of inflammation; and 
all varieties of nervous excitement are sometimes manifest in the highest degree 
without any inflammation ensuing. Even where pain and other nervous symp- 
toms are excessive, and are the result of mechanical or chemical injuries (such 
as crushed limbs, extensive burns. &c). inflammation sometimes does not follow; 
and this has led surgeons long to distinguish between irritation and inflammation. 
4. Inflammation readily occurs in parts, the nerves of which are paralyzed or 
have been divided." — pp. 249-250. 

L '- So far as it is known, the blood-vessels are the essential seat of the whole pro- 
cess of inflammation ; and although some of the exciting causes of inflammation 
(irritants), act on the nerves as well, yet others operate chiefly and essentially 
only on the blood-vessels. Hence we find that the causes predisposing to inflam- 
mation are circumstances chiefly affecting the vascular system." — p. 250. 

Having traced the essential operation of the causes of inflammation to be on the 
blood vessels and their contents, Dr. Williams next proceeds to the inquiry of 
" what is the character of their operation on the vessels, and what phenomena it 
develops." 

That the blood vessels are enlarged in inflammation is obvious to the most su- 
perficial observer, and has been proved by the experiments of Hunter, Alison, 
and others; but such is the case, too, in congestion. In what respect then does 
inflammation differ from congestion, and in which also the vessels are enlarged ? 

u It differs not only in the accompanying symptoms and in its products, but also 
in the observed condition of the vessels of the part. Thus besides greater pain 
and heat in an inflamed part, and earlier and more abundant effusions into or 
from it, the more florid hue of redness, the strong beating of the arteries leading 
to the part, and augmented quantity of blood flowing from its veins, clearly indi- 
cate that there is increased motion of the blood, instead of diminished motion, 
as in congestion." — p. 251. 

It is certain, from the observations of Lawrence and others, as well as from 
direct observation with the microscope, that the vessels in the vicinity of the in- 
flamed part are the channels of an increased flow of blood ; but if this were all, 
there would be no distinction between determination of blood and inflammation. 

u Microscopic research has established one great point of difference. The ob- 
servations of Thomson, Hastings, Kaltenbrunner, and Marshall Hall, have long 
clearly proved that there is more or less obstructionslo the passage of the blood in 



1848.] 



Williams' Principles of Medicine. 



157 



the vessels most inflamed. • Thus in the frog's web, when a part inflames from 
local irritation, the blood is seen to move more slowly in the part most irritated, 
and gradually accumulating in the vessels, renders them larger, redder, and more 
tortuous, until the motion ceases altogether in them, whilst neighbouring vessels 
are still the channel of an increased current. A chief point, then, in which inflam- 
mation differs from determination of blood, is in the retarded or arrested flow of 
blood in some of the vessels. This answers to the definition which we have 
given of inflammation : too much blood in a part, with motion (of that blood) partly 
increased, partly diminished." — p. 252. 

The cause of this retarded flow of blood through an inflamed part has always 
been a difficult problem for pathologists to solve. Cullen supposed it to depend 
on spasm of the extreme vessels. Wilson Philip ascribed it to a weakness of the 
capillaries, which he believed incapacitated those vessels from transmitting the 
blood. John Hunter taught that there was something active and vital in the en- 
largement of inflamed vessels, and he used the term "active dilatation;" and 
Kaltenbrunner, and other German writers, adopted the same idea, when they 
spoke of "vital turgescence," "turgor vitalis," "inflammatory erection," and 
analogous terms. The microscope shows the extreme vessels to be in a 
state of dilatation, not of spasm, and thus Cullen's hypothesis falls. To Philip's 
theory, Marshall Hall and others have objected by saying, that the capillaries, by 
their contraction, do not aid in the circulation of the blood, and that their " de- 
bility," therefore, cannot be a sufficient cause for interrupted passage of blood 
through them. The words of Hunter convey no meaning. The idea of Haller 
'and some of his followers, ascribing the circulation of the blood in part to cer- 
tain supposed properties of vital attraction and repulsion, by which the blood is 
drawn into, or repelled from particular parts, independently of all motion of the 
living solids — has been recently disinterred and advocated by Prof. Alison of 
Edinburgh. He regards changes in these assumed vital attractions and repulsions 
to be the chief elements in the process of inflammation. This hypothesis assumes 
the existence in the fluids and solids of the living body of properties as distinctly 
vita] as that of contractility or sensibility ; and, moreover, ascribes to these fluids 
and solids, powers of attraction and repulsion at sensible distances, like the attrac- 
tions of electricity, magnetism, or gravitation, yet distinct from all these, and 
sometimes opposed to them. It attributes, in the language of our author, to the 
living body a new physical power, and almost a discerning intelligence in the 
exercise of that power. Undoubted facts are necessary before this hypothesis can 
be received ; and Dr. Williams well observes : — 

" Now, before the existence of such a power can be admitted, it must be proved 
that the phenomena of living structures are not and cannot be explained through 
any known vital or physical agencies. We have already adduced and referred to 
arguments and observations to show that the known physical and vital properties of 
the living body will account for the chief phenomena of health and disease without 
assuming the existence of any forces of a mysterious character ; and we have now 
to consider whether the same thing may be done with regard to inflammation. 
If we succeed in explaining the nature and effects of inflammation by a reference 
to ascertained properties, it will be needless and unphilosophical to assume the 
existence of others, which are mysterious and unknown. We do not pretend to 
propose these explanations as complete or certain, but as the best that we can 
devise in the present state of science, and the most consistent with well-established 
facts; and it is very satisfactory to observe that the discoveries in chemical phy- 
siology made since the first edition of this work was written, so far from invalida- 
ting these views on the nature of inflammation and its results, go far to confirm 
and extend them."' — p. 255. 

What, then," is the cause of the stagnation or tardy motion of the blood in the 
most enlarged capillaries, in the midst of surrounding increased flow, and which 
is the great characteristic of inflammation'? Is it in the vessels, or in the blood, 
or in both? The latter, our author thinks, we shall find to be the true case. 

" In determination of blood, the arteries are enlarged, and so are the capillaries 
in due proportion ; the circulation is therefore equally increased. In congestion, 
No. XXXI.— July, 1848. 11 



158 



Bibliographical Notices. 



[July 



the capillaries are enlarged, without any increase 1 of the arteries: the motion is 
therefore impaired: but still, being gentle, it may diffuse itself through the mass, 
which moves slowly. But if to congested capillaries there be added the increased 
and abrupt force of the current from enlarged arteries, or if to determination of 
blood enlarged arteries and atonic congestion of the capillaries be joined, the pro- 
pulsive power of the current will be impaired. As in the experiment with the 
intestine, the blood will pulsate or oscillate in the distended vessels rather than 
pass through them; and the main current will pass through collateral anastomo- 
sing channels, which become the seat of simple determination or increased flow. 
This is just the state of things in the incipient stage of inflammation ; and if either 
the capillaries do not speedily recover their tone, or the arteries do not contract, 
the blood in parts becomes stagnant, its particles adhere to each other, and to the 
walls of the vessel, and the obstruction is confirmed. The arterial portions of 
some of the obstructed capillaries are still open, and exposed to pulsative force 
from the supplying arteries, which continues to strain their coats, and cause an 
oscillatory motion of their blood particles, but no passage though them. Such are 
the phenomena which we see under the microscope." — pp. 256-257. 

Hence, then, one cause of the retarded flow of blood in an inflamed part, is a 
weak, inelastic state of the capillary vessels: such, in fact, as exists in cases of 
atonic congestion. But it is very certain that the obstruction, as well as other fea- 
tures of inflammation, depend on " changes which take place in the blood within 
the inflamed vessels." John Hunter was aware of this, for besides describing 
the coagulation of the blood in the inflamed vessels, he mentions the adhesion of 
fibrin to their walls. Gendrin and others have noticed the coagulation of the 
blood in the inflamed vessels; and Dr. Marshall Hall attributed the obstruction of 
the vessels in inflammation to the adhesion of the blood globules to the walls of 
the vessels. Dr. Williams thought that microscopical observations should be di- 
rected to this point more specially than had hitherto been done; and, accordingly, 
in 1841, he made many careful examinations of the early stage of inflammation 
in the frog's web. We cannot afford the space to insert our author's recapitula- 
tion of them. They formed the subject of his Gulstonian lectures for 1841, and 
were published in the Medical Gazette of the same year. The result of nume- 
rous carefully repeated microscopic investigations was, that the chief cause of 
obstruction, as to the fluid within the vessels, was due to two circumstances,— the 
increased production of the white globules, and their remarkable disposition to adhere to 
the walls of the vessels and to one another. These investigations have been since 
repeated and confirmed by numerous experienced observers. 

The sudden and rapid formation of the colourless corpuscles, Dr. Williams thinks 
may be explained in this way : 

" The blood liquid is highly charged with protein, which needs only a further 
process of oxidation to assume the solid form of the deutoxide: this process is 
supplied by the free current of arterial blood (determination) which rushes into the 
obstructed portions, and brings the red particles, the oxygen carriers, in such forci- 
ble contact with blood liquor as favours the transfer of oxygen to the protein con- 
tained in it. As the protein becomes oxidized, it consolidates in a granular form, 
and the more readily around the oily molecules always diffused through the blood 
liquid; and these form the nucleoli visible in the larger granules. But the gran- 
ules also cohere in clusters, and form the pale corpuscles of various sizes which 
appear adhering to and creeping along the sides of irritated vessels." — pp. 261-2. 

The peculiar disposition of the white corpuscles to adhere to the walls of the 
vessels may be ascribed to the physical property of adhesiveness, common to soft 
bodies of glutinous materials. In the beginning of the obstruction of the inflamed 
vessels, the red corpuscles are little concerned ; they show no disposition to ad- 
here or form rouleaux; but in the period of total obstruction these flexible and 
elastic bodies can no longer pass, but become jammed in such numbers in the 
interstices of the white corpuscles, that the whole vessel speedily presents an 
almost homogeneous deep red color, from the great accumulation of red particles. 

" It seems, then, to be well established, that an essential part of inflammation 
is the production of numerous white globules in the inflamed vessels ; and that the 
obstruction of these vessels is mainly due to the adhesive properties of these glob- 



1848.] 



Williams' Principles of Medicine. 



159 



ules. The production of these globules must then be considered as a constant fact 
in the history of inflammation and nutrition."— p. 265. 

The further changes effected by inflammation are the modification in the func- 
tions of the involved vessels. This is manifested in different ways in different 
parts of the inflamed site. Where the flow of blood is increased, the functions 
will be exalted; whilst if it be obstructed, they will be more or less impaired. 
The effusions from inflamed vessels, although at first the same as from tense con- 
gestion and determination, present, as the inflammation advances, appearances not 
found in the products of mere congestion or determination. Much precise infor- 
mation on the nature of inflammatory effusions has recently been supplied by the 
microscope. 

" In the frog's web, after inflammation has continued some hours, there appear 
outside of the vessels ('especially of those in which the strongest current encoun- 
ters the most complete obstruction) white globules or corpuscles, with specks in 
them, exactly like the pale granular globules within the vessels. These are also 
found in various inflammatory effusions, and are called exudation corpuscles , gra- 
nule cells, ox fibrinous globules." — p. 268. 

In addition to these bodies, the fibrin effused by an inflamed membrane also 
contains a mesh of extremely fine fibres, first noticed by Messrs. Gulliver and 
Addison, as well as some portions of. solid effusion with no distinct structure, and 
which are either irregularly granular, like coagulated albumen, or completely 
amorphous and homogeneous; with the usual solids generated by the part, as 
mucous globules, epithelium scales, epidermis and blood corpuscles. 

The results of inflammation are thus given : 

" Inflammation is always attended with more or less effusion. Where the in- 
flammation is slight, this effusion may remove it by unloading the engorged blood- 
vessels; but where the inflammation is more intense, that is, where the obstruc- 
tion is considerable and the determination of blood strong, the effusion may go on 
to a great extent without resolving the inflammation. It is then that the more 
serious effects of inflammation result. The effused matters press on and pervade 
the adjoining textures, derange their nutrition, and impair their cohesion; and 
thus takes place the softening of textures, which occurs chiefly in those of a com- 
plex kind, which retain the effused matter. The continued obstruction in the 
inflamed part leaves the veins and lymphatics free to absorb, and the high pres- 
sure and determination of blood tend rather to promote this process of absorption. 
Hence, as new matters are effused, the old texture is compressed, disintegrated 
and absorbed; the finer exudation corpuscles and fibres themselves are removed 
or altered, and the large pus globules alone remain : this is suppuration. Or if the 
original obstruction of the inflamed vessels be extensive, or have been rendered 
so by the subsequent effusion, the supply of blood may be so stopped in a part, 
that it dies, and the dead part may then either be only dissolved and absorbed at 
its circumference, and separated from the living textures in form of a slough ; or if 
more extensive, the dead part may pass into decomposition before it can be sepa- 
rated; thus occur gangrene and sphacelus. If the inflammation be of a lower kind, 
the obstruction less complete, and the effusion more gradual, the nutrition of the 
natural texture is only impaired, not arrested, and from the increased deposition 
of solid matter, induration or consolidation takes place." — pp. 270-1. 

Such is our author's description of the process of inflammation in its intimate 
nature and phenomena, and we fear that our analysis has conveyed but a feeble 
idea of the admirable manner in which he has discharged a delicate and difficult 
task. We pass over the description of the symptoms, both local and general, of 
inflammation, together with the nature and symptoms of the terminations or re- 
sults of inflammation, which is simple and highly graphic, recent microscopical 
and chemical observations being laid under heavy contribution. We would direct 
particularly the notice of the reader to it ; he will obtain much valuable informa- 
tion on these important subjects in a compact and available form. 

In the treatment of inflammation and its results, though there is nothing of no- 
velty advanced, the views which should guide us are laid down most judiciously, 
and with a clearness which makes them comprehensible to the youngest student. 



160 



Bibliographical Notices . 



[July 



Chapter fourth is on structural diseases or diseases of nutrition. The author's 
classification of the elements of diseased structure is given in the following table. 

Increased=bypertrophy. 
Diminished=atrophy. 

f Induration. 



DISEASED 
NOTKITIOST 



Perverted 



Softening. 

Transformation and degeneration. 

. . \ Cicatrices, 
isuplastic < ^ , , 

1 f lalse membranes. 

f Cirrhosis. 



Deposits 



~\ Cacoplastic <( j^ro 



Aplastic 



artilage. 
, Gray tubercle. 
^Atheroma, &c. 
( Yellow tubercle. 
( Calcareous matter, &c. 



Non- 
malignant 

Malignant 



C Cysts. 
<v Tumours. 
£ Hydatids, &c. 
( Carcinoma. 

Encephaloma. 
r Melanosis, &c. 



Contraction 
Dilatation 

altered . Obstruction Growths 
mechanism: i Compression 
Displacement 
Rupture, &c. 

We shall be able only to briefly notice some interesting points. In a note at 
p. 362. speaking of the typhous-material in the intestinal follicles, bronchial 
glands, lungs. &c, mentioned by Rokitansky, Vogel, Engel, and other German 
pathologists, Dr. Williams, says: "Under the microscope, however, this matter 
exhibits nothing to distinguish it from bad fibrin or cacoplastic lymph; and in ac- 
cordance with the view in the text, I consider it to be such, and tending to involve 
in a process of sloughing the excretory follicles of the intestines by which it is 
attempted to be thrown off, or inducing a deposit in the lung which has various 
pernicious tendencies." — p. 362. 

The recent and extensive researches of Dr. H. Bennett, published in the Edin- 
burgh Monthly Journal* the results of sixty-three post mortem examinations, would 
seem to be confirmatory of the opinions of the German pathologists. In addi- 
tion to the organs already named, Dr. Bennett found infiltrated masses of the 
typhous deposit in the spleen. 

Under the head of cacoplastic and aplastic deposits, there is an exceedingly 
excellent article on the pathology of tubercle. Dr. Williams refers tubercle "to 
a degraded condition of the nutritive material from which old textures are renewed 
and new ones formed; and holds that it differs from fibrin or coagulable lymph, 
not in kind, but in degree, of vitality and capacity of organization." — p. 386. These 
views, which our author has held and taught for many years, have within a short 
period received demonstrative confirmation by the microscopic observations of 
numerous observers, and amongst others Mr. Gulliver, who detected in tubercle 
the materials of lymph, but in a degenerated and confused state, the cells being 
few, irregular, shrivelled, with imperfect nuclei and incapable of futher develop- 
ment; no fibres being perceptible, and the main substance being composed of 
panular or amorphous matter. 

"The circumstances which degrade the material of nutrition," observes Dr. 
Williams. " and lead to the deposition of cacoplastic and aplastic matter, may be 
either local or general. Of the local causes, congestion and the lowest and more 
chronic forms of inflammation have been mentioned as capable of determining 
cacoplastic deposits; but even in these cases it is probable that the general cause 
also more or less operates — that is, a degraded state of the plasma of the blood. 
Congestions and chronic inflammations certainly cause cacoplastic effusions; but 
then, such congestions and chronic inflammations do not easily occur in healthy 
subjects; and the want of health may imply that the plasma of the blood is bad 
in addition to the local cause. But practically, it is of great importance to keep 



See American Journal for Jan. 1848, p. 241. 



1848.] 



Williams' Principles of Medicine. 



161 



in view the local as well as the general cause, for the former is often more tractable 
than the other, and it is by guarding against it that slighter degrees of the general 
cause (diseased plasma) may be prevented from doing mischief. But the general 
cause, when present in great degree, leads to cacoplastic and aplastic deposits, as 
modifications of ordinary textural nutrition, independently of inflammation or even 
congestion. This general cause thus prevailing constitutes the chief element of the 
scrofulous diathesis or tuberculous cachexia, and we have before mentioned that 
a defect of the red particles and an excess of fibrin in the blood constitute its most 
remarkable feature. In this condition of the blood there is an increased disposi- 
tion to deposit, and often an abundance of the fibrinous or nutritive material, but 
an imperfect vitality or organizability of this material, so that when deposited in- 
stead of being assimilated to the textures, it forms the degenerated structure's or 
mere granular or amorphus deposits, which we have been describing. But with 
this condition of the blood, these deposits must be greatly promoted by all varieties 
of hyperemia, and prevail most in organs which receive the largest amount of 
blood. Hence, the peculiarly pernicious effect of inflammation of interna] organs, 
especially the lungs, in scrofulous subjects. Even acute inflammation may be 
unequal to raise the nutritive material to a plastic standard at which it may be 
organized or absorbed, or to mature it to the process of complete suppuration by 
which it may be speedily excreted : but the matter thrown out is cacoplastic or 
curdy lymph, remarkable for its opacity and want of cohesion, or a caseous kind 
of pus, inorganizable, inert, irremovable by absorption, and permanently obstruct- 
ing or compressing the structures in which it accumulates, until it gradually excites 
an irregular destructive suppuration or ulceration, forming vomica?, or imperfect 
abscesses pervading the structures, and without walls capable of healing, whilst 
under the depressing and irritating influence of the morbid matter decaying and 
becoming decomposed, the body wastes with hectic fever, night sweats, and col- 
liquative diarrhrea. So likewise fevers, by causing congestions in organs, lead to 
the production of a crop of these deposits, from which tuberculous disease takes 
its origin." — pp. 396-7. 

The several circumstances which contribute to render the lungs especially liable 
to tuberculous deposit, are, in the author's opinion, " 1. Their great vascularity 
and the large quantity of blood that passes through them, which makes them 
largely partake of any disorder in the condition of this fluid. 2. There being a 
chief seat of the formation of fibrin, that principle being more abundant in arterial 
than in venous blood. 3. The softness and yielding nature of their texture, which 
permits effusion to take place more readily than denser textures do. 4. Their 
exposure to external causes of diseases, whether by cold and irritations directly 
entering by the air-tubes, or by circumstances operating through the medium of 
the circulation. In hot climates, cacoplastic diseases affect the liver and other 
abdominal viscera more than the lungs; the same persons there suffering from 
chronic liver disease and dysentery, who, in a cold climate would fall victims to 
phthisis."— p. 398. 

In the treatment of tubercle, Dr. Williams states that his experience leads him 
to speak highly of the cod-liver oil; he says that it is 11 assuredly the most effica- 
cious of all medicinal agents in the treatment of cacoplastic and aplastic deposits, 
and one which, after two years' constant experience in its use, is still frequently 
surprising me by the wonders that it occasionally works even in aggravated and 
advanced cases of scrofula, mesenteric disease, pulmonary consumption, chronic 
pneumonia and pleurisy, and chronic rheumatism." — pp. 404-5. 

The best effects have generally resulted from the use of the purest kind. It is 
important that it should be as free from taste and smell as possible, and should be 
deprived of most of the stearine, by cooling and settling, or by filtration. That 
cod-liver oil owes its efficacy to the iodine it contains, Dr. W., in common vviih 
most practitioners who have employed it to any extent, does not believe. His 
theory of its mode of action will be found in the following extract. 

" Such an oil (purified) given in doses gradually increased to a table-spoonful 
three times a-day, in the great majority of cases, agrees well with the stomach and 
bowels, increases rather than impairs the appetite, and, if continued for some 
weeks or even months, promotes in a marked degree the function of nutrition. 



162 



Bibliographical Notices. 



[July 



increasing the strength as well as the flesh, and giving increment to all the tex- 
tures. Nor is this surprising when we consider that the nuclei or rudimental 
molecules of all structures appear to consist of fat, which the oil in its highly divisible 
state, supplies and renews in the manner most conducive to active and healthy- 
nutrition. Its peculiar fluidity and little proneness to change also enable it to per- 
vade all structures, and to penetrate even into imperfectly organized deposits, and 
by softening their concrete fatty molecules, and rendering more permeable and 
supple their whole mass, brings them more under the influence of the adjoining 
living parts, through the circulation in which either their vitality and nutrition are 
improved and maintained, or if incapable of improvement, they are gradually 
dissolved and absorbed away." — p. 404. 

The sections on non-malignant and malignant morbid growths, contain a well- 
digested summary of the best views on these subjects, and maybe consulted with 
profit. 

Chapter fifth treats of the classification, symptoms, and distinction of diseases. 
Semeiology and diagnosis are hardly touched upon. We had hoped that the au- 
thor's leisure would have enabled him to place these subjects on a level with the 
rest of the work* but this, it seems, either did not enter into his plan, or else he 
has, for some reason, been unable to accomplish it. These sections are very un- 
satisfactory. The section on prognosis has not fared better, but is somewhat re- 
deemed by the excellent account of the various modes of death. The chief va- 
rieties are thus tabulated: 



The concluding and seventh chapter, on prophylaxis and hygienics, of forty- 
four pages, has been nearly entirely added. Though it might, perhaps, have been 
advantageously extended, it is very valuable, and written with that sound discri- 
mination and good sense which distinguish all the practical portions of the work. 
It is, indeed, the best hygienic code that we ever remember to have met with. 

We now take a regretful leave of Dr. Williams. Of the character and value of 
the ' Principles, 7 the reader will be enabled to form an opinion from the analysis we 
have presented, and the extracts we have made; he will, we believe, think it 
entitled to claim his best attention, and that its perusal and study will be amply re- 
munerative. It is a work calculated to elevate the character of medical science, from 
its correct and lucid exposition of the great principles of scientific investigation ; 
and its plain, practical character, will recommend it to the student and practitioner of 
medicine and surgery. The author observes, u that whilst he feels grateful for the 
approbation with which this work has been honoured by scientific men, both in this 
[Great Britain] and foreign countries, he is especially gratified by the favour with 
which it has been received by practitioners of great experience." We think that 
the author has ample reason to express the hope that his ££ attempts to combine 
science with art, and to place the practice of physic on a more rational basis/' have 
n ot been altogether unsuccessful 



Death (cessation of function) beginning at the heart 



beginning at the breathing apparatus=Asphyxia or apncea. 
beginning at the brain=Coma. 
beginning at the medulla=Paralysis. 

beginning in the blood=Necrsemia (vsxpo?, dead; aifxa, blood). 




M. C. 



1848.] 



Hastings' Lectures on Yellow Fever. 



163 



Art. XIII. — Lectures on Yellow Fever ; its Causes, Pathology, and Treatment. By 
John Hastings, M. D., United States Navy. 8vo. pp. 69. Philadelphia: Lind- 
say & Blakiston, 1848. 

A close analysis of the various histories of yellow fever, as it has occurred in 
different localities and at different periods, that have been recorded by various 
observers, would show, we believe, very conclusively, that under this title are 
included several forms of disease, which, though they may resemble each other 
in some of their leading features, are, nevertheless, distinct in their true patholo- 
gical characters. It is difficult in any other way to account for the discordance, in 
regard to almost everything relating to the disease, which marks the descriptions 
of it furnished to us by different writers, of whose fidelity and accuracy of observa- 
tion we have no reason to doubt. Discrepancies of opinion in regard to the etiology 
of yellow fever, and discordant views in regard to its true pathological character 
we can easily understand, but we cannot account for the history of the ordinary 
symptoms and progress of the disease, and of the lesions discoverable in the 
bodies of those in whom it has proved fatal, furnished to us by one authority, differ- 
ing materially from the history furnished by another authority of equal respecta- 
bility, excepting upon the supposition that the two histories have been drawn from 
cases not of the same, but of different affections, resembling, but not identical with 
each other. 

In the work before us, Dr. Hastings furnishes us with the result of his observa- 
tions upon the causes, pathology, and treatment of yellow fever, which certainly 
differ in many important particulars from the observations recorded by others. 
As this gentleman's opportunities for studying the disease have, however, been 
unquestionably very extensive, his conclusions in relation to the disease are de- 
serving of an attentive consideration. 

In relation to the all-important and much contested question of the cause by 
which the disease is produced, Dr. Hastings is very positive that the yellow fever 
is generated invariably by the malaria or exhalations from an alluvial marshy soil, 
subject to periodic inundation and draining ;• the poison being eliminated during 
the process of desiccation under a high degree of solar heat. He states it as a 
positive certainty, that where yellow fever prevails, there is also found every va- 
riety of intermittent, and very generally, all varieties of remittent and bilious 
fever; these diseases, arising, in his opinion, from the same poison, but in differ- 
ent degrees of intensity. 

This error has been so frequently and conclusively refuted, that we must ex- 
press our surprise that Dr. H. should again bring it forward and announce it in so 
positive a manner. Though the facts he adduces in reference to the circumstances 
under which the disease occurred in the lower portion of Florida, and on the coast 
of Mexico, would appear to establish the correctness of the views advanced by 
him ; yet allowing to these facts all the weight that can be justly claimed for them, 
they are met by a host of others, which are entirely opposed to the conclusion 
which the author has drawn from them. 

Dr. Hastings has never seen a single instance where there was the least cause 
to suppose that the fever originated on board of ship, notwithstanding he has fre- 
quently seen ships in the conditions said to give rise to it; and never saw it on 
board of any of them, unless it was prevailing on shore, and then, even, he has 
seen vessels escape for a long time, when, according to the views entertained by 
others, they should have originated the disease. 

The facts adduced by the author in support of this statement are, we confess, 
particularly strong, but they do not strike us as conclusively supporting his general 
position in regard to what he supposes to be the only source of yellow fever. 

Dr. Hastings believes, that in every instance in which the disease occurs on 
board of ships, whether at sea or upon the coast, it is produced by malaria carried 
to them from the land through the medium of the air. The evidence which the 
author cites in proof of this position, is, in our opinion, not very strong. If the 
malaria giving rise to yellow fever can be conveyed to great distances through the 



164 



Bibliographical Notices. 



[July 



air undispersed, and undiluted by the latter, how happens it that when the yellow 

fever makes its appearance in a city, it is very generally confined to particular 
districts, beyond which it is seldom found to extend ? 

Our author denies the contagious character of yellow fever. He does not 
believe it possible to create the disease in a person confined among, and waiting 
upon any number of those affected with it, provided these are removed from the 
district where the disease was contracted, to a position known to be free from its 
invasion, and attended by persons who had not been exposed to the disorder, other- 
wise than by contact with the sick. He has seen at Indian Key, Florida, where 
the naval hospital was situated, in the epidemic of 1841 and '42. patients admitted 
in every stage of the disease, and even the bodies brought there of those who 
had died of it at other places, and yet without a single case occurring upon the 
island. 

The history of the symptoms and ordinary progress of yellow fever as laid down 
by Dr. Hastings differs in some particulars, from that given by others. It certainly 
does not agree, in a few important points, with the general features and march of 
the disease, as it has fallen under our notice in Philadelphia. The remarkable 
subsidence of all the more violent symptoms, which usually takes place about the 
third, fourth, or fifth day of the disease, and leads the inexperienced observer and 
the deceived patient to conceive hopes of recovery, when, in very many instances, 
the remission is to be followed, after a few hours, by the black vomit and a state of 
collapse, is a circumstance, remarks Currie, in his work on the Endemic Diseases 
of the United States, without a parallel in the history of fevers, and may therefore 
be considered as pathognomonic of yellow fever. This peculiar feature of the dis- 
ease, which is noticed by almost every American authority, is wanting in the gene- 
ral description given of it by the author ; though in his remarks on the prognosis, 
he notices, incidentally, as a remarkable feature of the disease, a complete remis- 
sion of the more prominent symptoms, which frequently occurs about the fifth day. 

In regard to the pathological anatomy of the disease, the following account is 
given by Dr. Hastings : 

"The brain and its membranes show in all cases results of active and extensive 
disease. The substance of the brain is rather firmer than natural, and completely 
engorged with blood, both upon its surface and interior structure: the ventricles 
are generally filled with a yellowish or bloody serum, although in some cases 
they are preternaturally dry ; yet the amount of bloody serum contained within the 
cranium generally is very large. The substance of the brain is so fully charged 
with blood, that when the medullary matter is cut across, numerous points bleed 
freely; and its whole structure is so coloured by the amount of blood contained in 
it, that there is but little difference existing between the medullary and cineritious 
matter. The membranes of the brain are all thickened; the dura mater particu- 
larly so in the region of the superior longitudinal sinus; and the glands of Pac- 
chioni are very much enlarged. The arachnoid membrane is greatly thickened, 
of a pearly hue, and tears with difficulty, compared with its delicate normal condi- 
tion. The pia mater is thick and whitish, like the arachnoid, to which it is firmly 
adherent ; there is often a quantity of partially organized lymph thrown out upon 
the surfaces of these two membranes, sometimes an eighth of an inch in thick- 
ness ; and I have even seen it nearly a quarter of an inch thick, having found 
these two coverings so thickened and strengthened by the process of inflammation, 
that I have held the whole mass of the brain, engorged as it is, and with the dura 
mater attached, by these two delicate membranes, that in their natural condition 
break at the slightest touch. • 

" The alterations of the spinal marrow and its membranes are the same as those 
found in the interior of the cranium. The vessels of the membranes of the brain 
and spinal marrow are greatly distended with blood. 

" The heart and lungs are not at all affected in yellow fever." — 

" The stomach is filled with, or contains a large quantity of black vomit; its mu- 
cous membrane is thickened to twice its healthy condition; it is dark-coloured, 
softened, and in a state of sphacelus, and frequently removed in large patches, 
particularly about the cardiac orifice. Throughout the rest of its surface, it is so 
soft that it is easily removed by the handle of a scalpel, or the finger nail, and it 
is also about this orifice and smaller curvature, greatly injected with blood. 



1848.] 



Hastings' Lectures on Yellow Fever. 



165 



Throughout its surface, are small bright scarlet spots, looking so much like fresh 
drops of blood, that I have seen the finger of those unaccustomed to these exami- 
nations, passed over, them, thinking to brush these stains away. But they are 
fixed in the mucous membrane. This condition extends to the pyloric orifice ; 
from this out, the intestines, both large and small, are unaltered and natural, with 
the exception of a slight degree of congestion or injection of the mucous mem- 
brane of the duodenum." 

u The liver undergoes a very great change. Tt is rather contracted and of a 
yellow colour, resembling very much the colour of old box-wood; this is particu- 
larly observable on the anterior part of the right lobe, although it pervades more 
or less its whole structure. Its substance is very much firmer than natural, in- 
deed, it is almost of a cartilaginous consistence; so much so, that it is nearly im- 
possible to penetrate a piece of it with all the force you can exert, when holding 
it between the fingers and thumb. It cuts with a hard, shining surface, and tears 
rather smoothly; its normal or granular appearance being almost or entirely lost." 

"The gall-bladder is natural and contains a moderate quantity of dark bile. 
The spleen is unaltered, except in cases where the deceased had suffered from 
frequent attacks of intermittent fever ; in these cases it was enlarged and softened/"' 

" These comprise all the changes effected by a fatal attack of yellow fever ter- 
minating upon the seventh day. 

" In the second case, wherein the disease comes to a fatal issue upon the four- 
teenth day or at a later period, very different pathological appearances present 
themselves. In these cases, the brain and spinal marrow are softened; their 
membranes are thickened, and there is generally a very large amount of yellow- 
ish or bloody serum within the cranium and spinal canal. The heart and lungs 
are healthy. The stomach is in much the same condition as already described: 
but the mucous membrane of the duodenum, small and large intestines, is greatly 
injected, thickened and softened, of very dark colour, and in some cases removed 
or destroyed in patches. The glands of Peyer and Brunner are injected and en- 
larged. The whole track of the mucous membrane resembling the change of 
structure met with in patients dying of typhus fever, but not to the same extent. 
The stomach is sometimes filled with black vomit, and the intestines contain dark 
matter resembling it. The mucous membrane of the bladder is injected with 
blood, and spotted with many scarlet points. The spleen, if altered at all, is rather 
softer than natural." " The liver is engorged with dark blood; about natural size, 
of dark colour and softened. The kidneys and other viscera are found to be in nor- 
mal condition. The blood remains in its liquid state in those who die; but there 
does not appear to be any peculiarity in that taken from yellow fever patients. 
It is observed to be cupped, has the buffy coat and same appearances as all blood 
taken from those suffering by active inflammation and a high state of fever. It 
contains, doubtless, a large amount of bile or its constituents, owing to the crip- 
pled or suspended functions of the liver." 

Dr. Hastings has made a strange misstatement in commenting upon M. Louis's 
account of the pathological changes observed in the fatal cases of yellow fever 
observed by him at Gibraltar in 1848. So far from the latter having never inquired 
into the condition of the brain and spinal marrow, as our author asserts, but pass- 
ing them by without a word and even without observation, M. Louis informs us, 
that he examined the brain and spinal marrow with great minuteness; the 
changes he discovered he did not consider, however, peculiar to yellow fever, the 
same being met with in typhus fever and other diseases. 

In the treatment of the disease, Dr. Hastings's chief dependence is in bleeding 
in the early period of the stage of excitement. Bleed, he remarks, ad deliquium 
animi— the amount of blood should not be regarded in the least — let it flow until 
the fever breaks, and the skin upon the forehead becomes moist. Calomel in 
large doses, followed by the sulphate of magnesia; blisters to the epigastrium 
and hypochondrium ; — the blistered surface being dressed with mercurial ointment, 
in order to bring the system under the influence of mercury, and to keep up a mild 
degree of ptyalism for about seventy-two hours from the commencement of the 
attack: during which time not a mouthful of anything should betaken into the sto- 
mach unless the vomiting continue. The bowels to be kept open by enemata of 



166 



Bibliographical Notices. 



[July 



Castor oil, turpentine, and some mucilage; the thirst to be allayed by ice or 
iced water held in the mouth, but not swallowed. 

For irritability of stomach, he directs from a quarter to half a drop of creasote, 
dissolved in ether or acetic acid, every hour, — combining it, when there is great 
excitement of the nervous system, with small doses of morphia. Iced water is to be 
kept constantly applied to the head, and the skin sponged with cold water when 
it becomes hot and dry. Sinapisms are directed to the spine to relieve the pain 
in the small of the back. 

When, as it sometimes happens, after the lapse of twenty-four or forty-eight 
hours, or more, the skin becomes hot and dry, with violent pain in the small of 
the back and throbbing pain in the head, with disposition to coma, the author di- 
rects a repetition of the bleeding; and is satisfied in his own mind that he has 
saved life by so doing; although, he remarks, the necessity for a second bleeding 
does not arise in more than one case in two hundred, or at least in one hundred. 

" When the above system of treatment is carried out, rigorously, the patient 
generally, on the fourth day, but at most universally on the fifth, is free from all 
fever, and has not a bad symptom left, and desires something to eat, and if he be 
moderately indulged with a little gruel of tapioca or some such innocent diet, 
sweetened, sliced, and seasoned with wine, he will improve very rapidly; at 
the same time, that is, from the fourth or fifth day, he should be allowed to drink 
weak brandy and water — this is one of the best stimulants that can be employed 
— but he should be stimulated gradually; and, from this time, no other medicine 
will be required than small doses of extract of colocynth or taraxacum and blue 
mass. Where the nervous system is much disturbed, small doses of strychnia 
can be added with advantage, followed occasionally by a Seidlitz powder, merely 
sufficient to correct the tendency to constipation, which exists for some time dur- 
ing recovery." 

Dr. Hastings considers that no disease is more entirely under the control of 
medical treatment than yellow fever, nor is there any one more imperatively de- 
manding it. 

We have considered the above notice of the work before us due to its author. 
His opportunities for studying an important disease have certainly been sufficiently 
extensive, and his object in publishing the result of his observations, which are in 
the main interesting, has been evidently to instruct his fellow-practitioners. While, 
however, Dr. H. feels a firm conviction of the truth and correctness of the views 
he has advanced, we fear that his estimate of the facts that have fallen under his 
notice has been, occasionally, somewhat superficial and one-sided, and that his 
deductions cannot be received as invariably accurate; while, in more than one 
instance, the style in which his observations are communicated is liable to well- 
founded objections. D. F. C. 



Art. XIV. — 1. Thirtieth Annual Report of the Physician and Superintendent of the 
McLean Asylum for the Insane. Boston: 1848. 

2. Twenty-fourth Annual Report of the Physician and Superintendent of the Retreat for 
the Insane. Hartford : 1848. 

3. Thirty-first Annual Report of the State of the Asylum for the relief of Persons de- 
prived of the use of their Reason. Philadelphia : 1848. 

4. Twentieth Annual Report of the Physiciaji and Superintendent of the Western Asy- 
lum. Richmond, Va.: 1848. 

5. Annual Report of the Superintendent of the Kentucky Lunatic Asylum. 1848. 

6. Reports of the Physician, and the Superintendent and Resident Physician of the Lu- 
natic Asylum. Columbia, South Carolina: 1847. 

1. Dr. Bell's report is unusually brief, being restricted to a general view of 
the institution and its results for the year." He has confined himself to these narrow 
limits, for the purpose of giving room to the accompanying communication from 
a committee of the Trustees of the Massachusetts General Hospital, on the history 
and results of the administration of sulphuric ether as an anaesthetic agent. 

The following are the statistics of the McLean Asylum for the year : 



1848.] Insane Hospital Rqwrts. 167 

Males. Females. Total. 

Patients at the beginning of the year 88 85 173 

" admitted during the year -, - 94 76 170 

Whole number under care during the year - - 182 151 343 

Discharged during the year - - - - 89 81 170 

Remaining at the end of the year 93 80 173 

Of the patients discharged; there were cured - 42 45 87 

u 11 11 u much improved 4 5 9 

" " " " improved 9 7 16 

" " " " unimproved 15 6 21 

« " " died 12 9 21 



" The bill of mortality," says the report, " is unusually large. This is ascribable, 
in part, to the fact, that in the preceding year the number of deaths was only 
nine — less than half the ordinary average; throwing upon the then ensuing period 
quite a number of aged, feeble, and epileptic. The existence of a severe, intract- 
able, epidemiG dysentery, prevalent also through the county, occasioned us the 
loss of twelve patients, out of eighty in our household who were seized with the 
disease." 

The large ratio of cures is attributed to a provision by which the Asylum is 
enabled to retain almost every case until a fair trial of restorative means was 
made. Could other institutions enjoy a similar advantage, the number of cures at 
many of them would be materially augmented. 

Dr. Bell makes the following remarks upon the subject of new remedies. u It 
has been our aim to adopt any outlay for every real improvement which the expe- 
rience of the world has ottered in treating those disorders, one of the symptoms 
of which is alienation of mind.- Aware, from frequent disappointment, that many 
of the novelties, moral and medical, which furnish a hope to the sanguine, and a 
newspaper paragraph to the curious, have but an ephemeral existence, we have 
each year found ourselves less hopeful as to new means of treating the insane, 
and have been gradually attaining the belief, that that institution which most 
closely pursued and thoroughly carried out the views presented a half century 
since by Pinel and Tuke would best fulfil its great end. The investigation of Mo- 
reau and others, into the properties and effects of the drug termed hachisch, in 
producing a continuous state of happy reverie, calculated to replace simple melan- 
choly or functional nervous depression ; and the recent discovery of the effects of 
those wonderful agents, the inhalation of the vapour of ether and chloroform, re- 
kindle the hope that some forms of insanity may yet prove to be more immedi- 
ately under the controul of direct medical means, than they have been found under 
the present advance of science." 

2. From the report of Dr. Butler, of the Hartford Retreat, we glean the follow- 
ing items: 

Malea. Females. Total. 



Patients at the beginning of the year - - 56 62 118 

" admitted during the year - - 39 . 54 93 

Whole number under care during the year 95 116 211 

Discharged during the year 36 53 89 

Remaining at the end of the year 59 63 122 

Of the patients discharged, there were cured - 12 28 40 

" u u u much improved 5 5 10 

" « « « improved 8 6 14 

" " « 11 unimproved 7 6 13 

" « ' " died .4 8 12 



Causes of Death. — Epilepsy 1 ; exhaustion 3 ; apoplexy 1 ; consumption 1 ; old 
age 1; marasmus 1; paralysis 1; disease of brain 1; uterine disease 1; suicide 1. 

Since the opening of the Retreat, 1764 patients have been admitted, and 1642 
discharged. Of the latter, there were recovered 942, improved 557, died 143. 

The following remarks on some of the causes of insanity are worthy of notice: 

" Of the one hundred and eighty-seven female patients admitted during the 
past three years, 34 per cent, were the wives of farmers or mechanics. It must 



f 



168 



Bibliographical Notices. 



[July 



be that this is an undue proportion of the comparative number of that class in the 
community. Many of these are young women, who leave nursing, or quite young 
children at home. The frequency of this occurrence, and its obvious causes, re- 
quire more than a passing remark A few brief suggestions may lead, hereafter, 
to a better understanding of these causes, and consequently to their avoidance. 
Many of this class present themselves at the institution ; either in the high excite- 
ment of acute mania, or in the deep and oftentimes suicidal depression of melan- 
cholia; in all cases greatly exhausted, and most evidently worn down by hard 
w 7 ork and anxiety, undue mental and physical effort, as classed in the table; 
though sometimes, other and more obvious causes (though less real), are received 
and recorded by us. In many cases, not having received in early life a judicious 
physical or moral training for her new and arduous station, the young wife, im- 
pelled by affection and an honest pride to her utmost efforts, soon finds that, with 
her increasing family, the burden of care and duties increases; while her physical 
strength and capacity of endurance diminish even in a greater ratio. 

"in economy sometimes deemed necessary, now often ill judged and cruel, 
leads the husband to refrain from supplying the necessary domestic assistance ; 
the nurse is discharged too soon, and, sometimes, no suitable one is provided. 
In addition to their own proper household, an eagerness for gain leads him to take 
boarders from the operatives in the neighbouring factories, for whom the wife 
must cook and otherwise provide, and often the day proves too short for the ac- 
complishment of the necessary duties, and her labours are protracted to a late 
hour of the night, and the broken slumbers of the remainder of its hours of rest 
give little refreshment. 

"Thus, it must naturally follow, that, between childbearing, nursing, and the 
accumulation of household duties and drudgery, the poor, heart-broken, and dis- 
appointed wife loses in turn her appetite, her rest, and her strength ; her nervous 
system is prostrated, and, sinking under her burden, she seeks refuge in a Lunatic 
Hospital. This process of inducing insanity, is by no means limited to the above 
mentioned classes; the same thing, differing more in degree than in manner, is 
too often seen elsewhere." 

3. In the Asylum at Frankford, the number of patients at the beginning of the 
year, was 

Males. Females. Total. 



26 32 58 

Admitted during the year 16 21 37 

Whole number during the year 42 53 95 

Discharged during the year - 40 

Remaining at the end of the year - 55 

Of the patients discharged, there were cured - 24 

u " " " much improved 2 

« " " " improved - 3 

" u 11 u unimproved 8 

" " " died - 3 



Causes of Death. — Inflammation of bowels, 1; apoplexy supervening upon the 
paralysis of the insane, 1; mortification following erysipelas, 1. 

The method of endeavouring to manage the insane by equivocation, deception 
and falsehood is so general in the community, that the following judicious remarks 
cannot be too widely circulated. 

" We think it necessary to call the attention of those who may have the care 
of the insane, to the great importance of observing towards them such a course 
of conduct, as will tend to inspire them with confidence — of treating them with 
kindness and candour, and especially of avoiding every attempt to impose upon 
them, by promises which are not meant to be fulfilled. 

"There seems to be a fear prevalent with many, of speaking frankly to the 
insane on the subject of their disease, and great care is taken to avoid any refer- 
ence to the subject. This, in many cases, induces a resort to equivocation, or to 
holding out to patients other motives or objects than the real ones, for the course 
which is deemed necessary to be pursued towards them. It is too often thought 



1848.] 



Insane Hospital Reports. 



169 



to be not only justifiable, but advantageous to influence the insane in this way, 
though they nearly always have acuteuess enough to discover the deception, and 
are far more apt to have their suspicions excited, and their fears increased, than 
to be benefited in any way by such treatment. When it becomes necessary to 
resort to restraint on their movements, or to a course of medical treatment to 
which they object, it is much better to inform them of their real condilion, and of 
the necessity of submitting for a time to the judgment of others, ralher than at- 
tempt to gain upon them by misrepresentations, or promises which are never in- 
tended to be fulfilled. It may be said, that the insane generally are not averse to 
placing confidence in those about them, and that it is not until they find that some 
advantage has been taken, or some deception practised upon them, that they be- 
come suspicious, and imbibe that dislike for their nearest friends, which is thought 
to be so common in their disease. 

( '- These remarks apply especially in cases where it is contemplated to remove 
the insane from their homes, and to place them under treatment in an asylum or 
hospital. 

" When this is decided on, they should always be informed of the determina- 
tion; and, if they are capable of understanding them, the reasons which have 
induced their friends to come to that conclusion should be explained. When this 
is done in a proper manner, it is very seldom that they will not submit quietly to 
the wishes of their friends; and invariably such a course occasions much less 
trouble and anxiety than when a different one is pursued. The patient enters the 
institution in a much better condition, for the beneficial action of those means 
which are to restore health. In several instances which have come under our 
notice, the disease has been aggravated, and recovery manifestly retarded by the 
irritation and excitement that have been produced, in consequence of the want of 
that respect and regard for the feelings of the insane, which would dictate the plan 
of dealing with them which is here recommended." 

4. Tn consequence of an act of the Legislature of Virginia, requiring the super- 
intendents of Public Institutions in that State to prepare their annual reports up to 
the 30th of Sept., instead of to the close of the Calendar Year, the present report 
of Dr. Stribling, of the Western Asylum, embraces a period of but nine months, 



from the 1st of Jan. to the 30th of Sept. 1847. 

Males. Females. Total. 

Patients on the 1st of January 123 94 217 

Admitted during the nine months 19 20 39 

Whole number under care ----- 142 114 256 

Discharged during the nine months - 49 

Remaining Sept. 30th 207 

Of those discharged, there were cured - 23 

" " " much improved - 2 

" 11 11 improved - - 3 

" u " unimproved - - 2 

" " eloped - - - - 1 

» " died - 18 



Causes of Death. — Marasmus, 4; epilepsy, 3 : pulmonary disease, 3; inflamma- 
tion of brain, 1; congestion of brain, 1; dysentery, 1; typhoid fever, 1; hydro- 
thorax, 1 ; chronic diarrhoea, 1 ; causes unascertained, 2. 

u Within the last few months," says the report, an all-wise Providence has 
seen fit to afflict us with a typhoid fever, which, confining itself to no grade, sex 
or color, prostrated .upon a bed of languishing, many of our officers, attendants, 
patients, and servants. The whole number thus attacked was about thirty. The 
disease seemed not malignant, nor were its symptoms unusually violent; but it 
was remarkable for the tenacity with which it clung to its subjects. Few became 
convalescent until they had lingered four or five weeks, and some scarcely com- 
menced improving until after the seventh or eighth week of their illness. Only 
two deaths occurred, one of them a female patient, the other a servant. 

Notwithstanding the large additions which have been made to this institution 
within a few years, all its apartments are now continually occupied, and during the 
nine months embraced by the report, eighty -four applicants were refused for want 



170 Bibliographical Notices. [July 

of room. Dr. Stribling therefore recommends that further accommodations for the 
Insane of the Commonwealth be provided. 

5. By the report of Dr. Allen, of the Kentucky Lunatic Asylum, it appears that 
the number of patients in that institution, at the beginning of the year, was 



Males. Females. Total. 

129 96 225 

Admitted during the year , - - 54 32 86 

Whole number 183 128 311 

Discharged during the year 64 

Remaining at the end of the year .... 247 

Of the patients discharged, there were cured - 29 

a u « a u removed" - 10 

" 11 " eloped - 2 

« " « died - 23 



The people of Kentucky never have been, and appear still not to be aware of 
the importance of treating insanity in its early stages, and Dr. Allen devotes a con- 
siderable portion of this report, as he has of those which preceded it, in pourtraying 
the advantages of bringing patients to the asylum soon after the commencement 
of their disease. Of the eighty-six patients received during the past year, only 
ten were recent cases. 

A large addition to the buildings of the institution is now nearly complete. In 
its construction much labour by the inmates of the asylum was expended, and that 
part of the report relating to this subject is fraught with such interest, that we 
extract it. 

" The entire year has been one of almost unremitting toil to officers and attend- 
ants, and of much labour to patients. An amount of labour has been performed, 
I think I may justly say, which has nowhere else been equalled by lunatic hands. 

u Those hands that have been employed about the improvements in progress, 
have worked steadily and willingly, and, I may add, with benefit to themselves, 
and advantage to the hospital. 

" I cannot stop to specify what has been accomplished, but merely mention a 
few of the more important jobs that have been performed by them. 

" The whole of the stone in the foundation of the new building has been quar- 
ried and hauled; and the brick laid in its walls, (about 1,100,000,) with the ex- 
ception of moulding, were made and carried to the scaffolds, the mortar mixed 
and borne by lunatics. The foundation, 112 feet long, by 64 feet wide, and 10 
feet deep, was dug; also, drains traversing every department of it, uniting in a 
common one leading thence to a cave below the spring, a distance of 800 feet, 8 
feet wide by 10 feet deep, and stone gotten and placed at hand to build, through- 
out these drains, a sewer, with 18 inch side walls, with a covering of large flag 

stones, amounting to about cubic feet of digging, and 300 perches of stone 

work. 

"Such are the achievements obtained by encouraging the insane to moderate 
labour. 

u In addition to all this, the ordinary labours have been performed, such as gar- 
dening, farming, &c, from all of which, abundant crops have been obtained." 

6. Two reports emanate from the medical department of the Lunatic Asylum, 
South Carolina — one by Dr. Trezevant the attending physician, the other by Dr. 
Parker, the superintendent and resident physician. The statistics for the year, 
according to Dr. Parker, are as follows: 



Patients at the commencement of the year ------ 70 

u admitted during the year 33 

Whole number under care 103 

Discharged during the year -29 

Remaining at the end of the year 74 

Of the patients discharged there were cured 17 

" " " u removed under improvement" - 5 

" " 11 eloped ------- i 

« " " died - 6 



1848.] 



Blakiston on Diseases of the Chest. 



171 



Dr. Trezevant's report includes under the head of cures, the five patients here 
stated to have been " removed under improvement.' 7 

The reports include an elaborate consideration of the various means of moral 
treatment. Dr. T. proposes, as a new method of diversion and exercise, a ma- 
chine of his own invention. As it is a novelty, we quote his remarks upon it. 
11 1 am, moreover, impressed with the belief, that if one was erected, that our now 
workers could be urged into action, by the spirit of fun and frolic. Many are 
willing to play off a practical joke, and take great pleasure in inducing them to 
enter into what they would call sport. The action would commence in play, but 
they would be compelled to go on with it, if the excitement of their feelings would 
not induce them to continue, and the workers would become partakers of the 
pleasure of the ride, and exhilarating effects of rapid movement in the open air; 
but, should they determine not to move, and positively refuse to work, still the 
very effort which they make to sustain their determination, calls the brain into 
action, and produces a new train of thoughts and feelings; and if they decline 
motion, they must hold by their hands, and use much muscular exertion, and my 
object will be in some measure accomplished in spite of themselves. So that 
whether they act in accordance to my wishes or their own will, the much desired 
objects will be effected. The mode proposed would be wheels connected toge- 
ther by an endless band, and so arranged as to act on a large horizontal wheel, on 
which seats could be placed similar to the flying horse. This would be exercise 
and amusement to all parties, and might be made to answer the purpose- of a 
rotary chair, and by the different positions to and from the centre, excite or di- 
minish the activity of the brain; it can be made to answer the purpose of a cir- 
cular swing, and, by the centrifugal force, rouse the brain to any extent, and with 
the centripetal motion depress it. The force required to effect this, I will make 
by an endless band, on which one or more patients shall walk, and arrange it, so 
that no possible injury can occur; and they shall not be exercised beyond their 
powers, but sufficiently to make them more healthy, and cheer their minds by 
seeing the effect of their apparent mischief on those revolving about them. I can- 
not but believe, that an instrument of this kind will be beneficial to all parties, 
and may. with a little ingenuity, be adapted to many useful purposes." 

P. E. 



Art. XV. — Practical Observations on Certain Diseases of the Chest , and on the Principles 
of Auscultation. By Peyton Blakiston, M.D., F. R.S.; Fellow of the Royal 
College of Physicians; Physician of the Birmingham General Hospital, and 
formerly Fellow of Emanuel College, Cambridge. 8vo. pp. 384. Philadel- 
delphia: Lea and Blanchard. 

The importance of auscultation as a means of diagnosis in the diseases of the 
chest being now almost universally recognized, no physician can be considered 
excusable who has not made himself acquainted with its principles and practice. 
With the consideration of auscultation, therefore, the present work commences; 
nearly one-fourth of its pages being devoted to this subject. The great object of 
the author has been to develope the principles of auscultation in as elementary a 
manner as possible; and, so far as mere description can do, he has succeeded in 
rendering the auscultatory sounds and indications plain and intelligible. In order 
to assist the novice and to prevent repetition in referring to the laws of sound, a 
short summary of such of its properties as are applicable to auscultation of the chest, 
has been prefixed to the chapters on the latter subject. The student will find the 
portion of the present work devoted to the principles of auscultation, a very useful 
manual in his investigation of this essential means of diagnosis at the bed side, 
where alone any certain and accurate knowledge of it can be acquired. 

The pathological and therapeutical observations of Dr. Blakiston in reference 
to some of the leading diseases of the thoracic organs, are, we are assured, the 
faithful report of facts observed in private and hospital practice. Tn almost every 
one of the one hundred and twenty-two cases, the details of which are introduced 
in the volume, the symptoms during life were witnessed and noted down by the 



172 



Bibliographical Notices. 



[July 



author: and, in the event of death occurring, he was either present at the examina- 
tion, or inspected the diseased parts after their removal. Dr. Blakiston, therefore, 
holds himself responsible for the accuracy with which the cases have been ob- 
served, and the fidelity with which they have been reported. 

The work is, therefore, to be received as a record of the personal experience of 
the author, raiher than as a systematic treatise on the diseases which it embraces; 
and it is this feature which gives to it its chief value and authority. 

The affections of the chest, to which the observations it records refer, are 
thoracic aneurism, chronic heart disease, circumscribed pleurisy, chronic pleurisy, 
plastic pneumonia, and phthisis pulmonalis. Upon the causes, symptoms, pro- 
gress, diagnosis and treatment of each of which, the remarks of Dr. Blakiston 
will be found invariably interesting, and generally sound and instructive. The 
reader is notified in the preface that " there are certain views of treatment per- 
vading these pages, which have resulted from the observation of disease in general, 
and of facts more numerous than those brought forward in this work.' ; These 
relate to the substitution of mercury for venesect' on in acute inflammations, more 
especially those affecting serous and fibrous membranes, and to the employment 
of tonic in combination with sedative remedies in a large class of chronic dis- 
orders. Such views are not peculiar to the writer, but still, they are by no means 
universally adopted, or canied out in practice. As they are, in his case, princi- 
pally founded on cases that have occurred in a populous manufacturing district, 
they maybe considered, perhaps, as inapplicable to the inhabitants of other locali- 
ties, where the nature of the employment and the surrounding atmosphere have 
a more invigorating effect on the constitution. A slight allowance, the author 
thinks, may possibly be required for this difference in circumstances; at the same 
time it must be borne in mind, he adds, "that many cases were observed among 
the higher classes, to whom this remark does not apply. Some old practitioners, 
of sound judgment, are of opinion that depletion can be less borne by persons in 
general at the present time than it could be forty or fifty years ago. There is pro- 
bably some truth in this, for, in proportion as civilization advances, and commercial 
enterprise is extended, the mind is more exercised, and the nervous system more 
taxed, so that to a certain extent the constitution is thereby impaired and debilitated. 
Be this as it may, it will hardly be denied by any that venesection has been, and 
is still practised with too little caution and discrimination." 

We cannot go to the full extent the author has in his opposition to venesection 
in the acute inflammatory diseases, for, however correct his remarks may be in 
reference to those diseases as they occur in the communities to which his practice 
was principally confined, they will not apply in all their force to the same class of 
diseases as they present themselves to the American practitioner. Nevertheless, 
many valuable practical hints may be derived from his exposition as well of the 
therapeutics as of the pathology of the several inflammatory and chronic affec- 
tions of which he treats. D. F. C. 



Art. XVI. — On the Blood and Urine. By John William Griffith, M. D., F. L S., 
&c, G. Owen Rees, M. D., F. R. S.. F. G. S., &c, and Alfred Markwick, M. D., 
&c , in one volume — pp. 182, 165, 113-460. Philadelphia: Lea & Blanchard, 
1848. 

The three treatises, contained in the volume before us, form a valuable addition 
to our yet scanty stock of works upon the blood and urine. The authors. w*hose 
separate productions have been thus collated, are well known for their industrious 
researches in the field of humoral pathology, and their opinions and observations 
are entitled to our fullest confidence. If it had been consistent with justice to them, 
we could have desired that the results of their individual labours might have been 
condensed into a single essay; a complete treatise would thus have been formed, 
and the reader spared the fatiguing recurrence of many statements necessarily the 
same in separate works treating of one subject. Although each of these has merits 
peculiar to itself, to which we will hereafter advert, they all possess in common 
the excellence of being clear in language and concise in detail, and the more 



1848.] 



Griffith on the Blood and Urine. 



173 



intricate analytical processes are rendered intelligible to every one who is tolerably 
familiar with chemical manipulation. The professional chemist, as well as the 
student and practitioner of medicine, will find much in their pages worthy of his 
attention. They are, moreover, the most recent works that we possess upon 
medical chemistry, containing the latest additions which have been made to the 
science. There is hardly any branch of medical investigation which has received, 
of late, greaier attention than this; it seems, too, to have taken at last the right 
direction in the subordination of premature theoretical application to a seveie 
analysis of facts. As Dr. Griffith says, " To argue that such investigations are idle, 
merely because each new truth which is elicited is not immediately applicable to 
the elucidation of some point in the history of a disease, or to the improved appli- 
cation of remedial means for its alleviation, is as absurd as, unfortunately, it is 
frequent." 

The first two of these manuals treat of the blood and urine ; that by Dr Griffith 
is a :i Description of the general, chemical, and microscopical characters of the 
blood and secretions of the human body," &c; that of Dr. Rees, is u On the analy- 
sis of the blood and urine in health and disease, and on the treatment of urinary 
diseases:" and the manual of Dr. Markwick is entitled, 11 A guide to the examina- 
tion of the urine in health and disease, for the use of students." It will be seen 
from this, that there are certain differences in the plan laid down by each of these 
authors, in consequence of which a full consideration of the whole subject is 
secured. The first of the works in the foregoing order, contains certain micro- 
scopical details, which are not touched upon in either of those which follow. The 
proximate principles are described before the compound fluids which they consti- 
tute; after which, an analysis is given of the more important healthy and morbid 
secretions. Dr. Griffith furnishes us also with a process adapted to the analysis of 
any fluid that may be presented for examination. His work will be found ex- 
tremely convenient for reference, as it contains a great deal of information in a 
condensed form. As an illustration of the fullness with which several subjects 
are considered, we would refer to the description of the bile (p. 137), in which 
its following constituents: the cholic, choleic, cholinic, choloidic, fellinic and bili- 
fellinic acids, besides biline, biliverdine, bilifulvine, taurine and dyslysine, are 
successively considered, and their chemical relations and physical properties enu- 
merated. 

The method to be pursued in making a quantitative analysis of the blood is 
given by Dr. Rees at some considerable length ; it is not difficult, however, for the 
reader to follow this intricate process, step by step, as the description of it is con- 
veyed in simple aud unambiguous language. The mode recommended by him 
is that of Andral and Gavarret, with some few modifications, and is applicable 
before the coagulation of the blood. When this has taken place, Berzelius"s method 
is to be empluyed. Both these and other processes are given in this work. 

The analysis of the urine is exposed more thoroughly by Dr. Markwick than by 
either of the others, and contains, moreover, the later additions to the science not 
included by them. He also gives a greater variety of tests for the recognition of the 
elements of this secretion. A very useful tabular view of the abnormal ingre- 
dients of the urine is introduced, in which these are referred to their chemical and 
pathological causes as far as known. The more profound study of the organic 
products found in this fluid is furthered by a number of chemical formulae exhibit- 
ing their composition. 

It would be difficult to specify all the interesting matters contained in these 
manuals, without extending this notice beyond its proper limits: we would, how- 
ever, in conclusion, draw attention to the very excellent observations of Dr. Rees 
upon the treatment of urinary deposits. The greater number of the cases of 
phosphatic deposits, in which the urine is at the same time alkaline, are referred 
by him to a tendency in the surface of the mucous membrane of the urinary tiact 
to the production of an alkaline fluid. He supposes that in these cases, a urine, 
too acid in quality, is secreted and becomes alkaline only after leaving the kid- 
neys, in cousequence of the irritation it produces upon the mucous membrare. 
His treatment is in conformity with this pathological view, and cases are intro- 
duced by him exemplifying its correctness. He says, " It may appear somewhat 
unaccountable to those who merely look to the chemical view of the matter, that 
No. XXXI.— July, 1848. 12 



174 Bibliographical Notices, [July 

any one should expect to render alkaline urine acid by the administration of al- 
kalies, but such was the treatment 1 adopted, and the result fully corroborated the 
correctness of the theory which suggested it as a crucial test." 

In order to exhibit the impropriety of making loo hasty conclusions from che- 
mical examination of the urine, he cites the supposition which has been enter- 
tained that cubebs and copaiba will produce albuminous urine, and affirms this 
opinion to be erroneous. Such urine, when tested with nitric acid, does, indeed, 
yield a precipitate greatly resembling albumen, but which is due to a vegetable 
matter contained in these drugs. As a proof of the correctness of this statement, 
he mentions that if the urine of patients treated with these remedies, be treated 
with ferrocyanide of potassium, after having been first accidulated wiih acetic 
acid, the vegetable matter will be but slightly affected, while the albumen, if pre- 
sent, would be at once precipitated He also states that, after the test with nitric 
acid, albumen soon sinks to the bottom of the vessel, but the vegetable matter 
will not do so until the urine begins to be decomposed. There may be much 
truth in these statements, but we do not think they are entirely satisfactory, for 
albumen has certainly been detected in the urine, by very experienced chemists, 
after the employment of these irritating remedies. 

It has also been stated, that the use of mercury renders the urine albuminous. 
Dr. Rees gives a table containing fifteen cases which tend to disprove this as- 
sertion. All of these fifteen patients were salivated with mercury, and albumen 
was not found in the urine of any. Dr. Rees relates a case showing the disappear- 
ance of albumen from the urine in a case of Bright's disease, after the salivation 
of the patient. 

To show the evil of relying solely upon the application of heat, as a test of the 
preseuce of albumen, Dr. Rees introduces a table, containing 482 cases taken pro- 
miscuously from the hospital wards, in 34 of which upon the application of heat 
to the urine there was a deposit resembling albumen, but consisting of the earthy 
phosphates. Thus seven per cent, of the whole number of cases might, by some 
persons, have been considered cases of albuminuria. " A little knowledge is 
indeed a dangerous thing," in hasty and over-zealous hands. We can sincerely 
commend these manuals to all desirous of information upon a subject of growing 
interest and importance ; they can find it certainly nowhere more clearly and con- 
cisely exposed than here. We regret to note, in a work otherwise so well got up, 
a number of gross errors in typography, which in a reprint are hardly excusable. 

M. S. 



Art. XVII. — Anniversary Discourse before the New York Academy of Medicine. No- 
vember 10th, 1847. By John W. Francis, M. D. Published by order of the 
Academy. New York: 1847. 8vo. pp. 112. 

We have read with much gratification the discourse of Dr. Francis, as a well- 
timed, high-toned, and sensible appeal to the profession upon topics in which they 
are deeply interested : opening with a rapid survey of some of the striking pecu- 
liarities of the age, which render the first fifty years of the century the most re- 
markable connected with the history of man, Dr. F. observes, that a " remark- 
able characteristic of our Republic" is the principle of association, which is so 
powerful an agent whether for good or evil, and of which the advantages have 
been chiefly felt in its application " to self improvement and the augmentation of 
knowledge, to eleemosynary and charitable designs, and to fiscal experiments." 
It is under the first of these heads that the institution whose members he was ad- 
dressing, was placed — an institution, resulting from the wants of the profession 
itself, and the community at large. 

" An Academy of Medicine in this city (New York) was a moral necessity ; 
it was demanded by the daily increasing perversion of a noble science, by the 
sullied dignity of an honourable vocation, by the predominance of evils of saddest 
issue, and by the long-neglected claims of injured humanity. This language can- 
not, 1 apprehend, be deemed too forcible, when contemplating the condition of 
practical medicine, in this our own day and generation. Yes, the venerable art 



1848.] 



Discourse before the N. Y. Academy of Medicine, 



175 



of physic, rich with the achievements of the mightiest intellects, and the accumu- 
lated wisdom of more than two thousand years, with its divine claims of origin, 
and its vast train of blessings in our behalf, seems threatened with distrust of its 
noble capabilities, to have lost of its repute as a disciplined science among us, 
and to have surrendered its long-earned resources to the specious appearances, 
and absurd practices, which the necromancers and zealots of the darkest ages 
might hesitate to tolerate. How sadly such a condition of the profession harmo- 
nizes with the great objects of the sacred art ! Philosophy can scarcely abide the 
reflections which spring from an examination of the causes which have led to the 
formation of this Association of the disciples of iEsculapius in behalf of their 
cherished science. That ignorance of the laws of life, of the rules of health, and 
of the remedial powers of medicinal substances, prevails to a wonderful degree, 
even in exalted places, is an incontrovertible position ; and hence the innumerable 
calamities which popular delusion in the curative art entails. Most unfortunate 
for its victims, like fraud in fiscal concerns, it has a wider influence in its effects 
than with the immediate objects with whom it traffics. Its dire malignity is often 
extended through a large circle of the unconscious and unsuspecting. 

61 There is at times an obtuseness in the public mind in regard to the legitimate 
claims of the profession, a want of discrimination in recognizing the genuine 
tokens of success, and an absence of veneration for the dictates of experience. 
The new, the striking some wild fancy, or chimera, a system which appeals to 
the curiosity, or flatters the imagination, is often suffered to blind the vision of the 
multitude to the utility of positive knowledge, and the appeal to unaided truth. 
Insensible or indifferent to the responsibilities of the profession, countenance is 
given by individuals of high social position, equally as by the illiterate and the 
vulgar, to measures, the inefficiency of which has been proved by long established 
facts. The wisdom slowly but surely earned by positive experiment, is thus 
thoughtlessly put aside for the speculations of the hour, and absurdities a thousand 
times exposed. How deservedly contemptible, nay, criminal, may all this be 
pronounced, in an age which boasts its general intelligence ! Yet what mind, of 
comprehensive views, that looks truth in the face, observes the relation of things, 
and calculates consequences, but must feel assured that this great enormity must 
lead to its own destruction, and that the hour of retribution must arrive. Its tole- 
ration cannot much longer be granted. The mischief which it engenders, wide 
as is its influence, assimilates little with the enlightened philanthropy of the times; 
it must disperse as the product of a period, portentious of novelties, too much 
devoted to sordid concerns, and criminally indifferent to the value of human life. 
Nor is there need of any marvellous sagacity to foretell the future. The abettors 
of these unhallowed schemes already appear dissatisfied with their own doings; 
and, distracted by the conclusions of their own understandings, already they begin 
to suspect the fidelity of their senses, and seem alarmed at the skepticism of their 
deluded victims. To hasten so beneficial an advent, to disenthral a people thus 
abused, on a subject of deeper interest than even wealth, according to popular 
estimation, is a design of no ordinary importance. More exalted motives to action 
in this deporable condition of medical practice, can never influence man in his 
associate relation, nor higher objects awaken his zeal, or greater good follow his 
efforts. With fixed intentions to exercise a duty which has become imperative, 
if we would claim the homage of pure disciples in our high calling, and in default 
■of public solicitude, the errors and absurdities which beset us, to the disgrace of 
the Hippocratic art and the sacrifice of human life, must be visited with a whole- 
some supervision, both as a labor of love and as a duly the most exalted. A 
strenuous yet peaceable policy is to be cherished, and liberal maxims inculcated ; 
yet between alternatives, a preference is to be given to a just and honourable 
maintenance of legitimate medicine, rather than a disgraceful repose when her 
proper sphere is invaded. Nor can a richer recompense be promised to the state 
at large from the measures which this Academy contemplates, in its potential cha- 
racter, by a wise exercise of its powers, and an unwavering prosecution of its 
disinterested designs." — pp. 9-12. 

Upon this text, Doctor Francis enlarges through several pages, showing in a 
forcible manner, and with the warmth of an ardent votary ot the science whose 
noble claims he' vindicates, the errors under which society labours respecting it, 



176 



Bibliographical Notices. 



[July 



and respecting these who are the honourable and intelligent exponents of its great 
and charitable mission. He warns the sound physician that while he has an 
abiding confidence in the great truths of his profession, and embraces that "phi- 
losophy which enlarges our powers and thus blesses us," he must not confound " it 
with that empiricism which robs us of our dearest possessions, and cripples the 
means on which humanity relies." 

" It cannot be disputed that the widest difference exists between that wise con- 
servatism which advances with cautious induction by known truths, to others still 
hidden, and that restless spirit of innovation, which, in order to secure its ends, 
spurns all control, and rejects the clearest demonstrations established by our pre- 
decessors for the best interests of man. I am ready to allow that every man's 
brains are not possessed of like faculties ; and we know that there are unconscious 
dupes as well as artful knaves, and that the organ of credulity is in some cases of 
so disproportioned a size, as to usurp the controlling faculties of some of the best 
minds. But philosophy has her prescribed laws, and is tenacious of allegiance to 
them. She presents herself in the simplicity of truth : and if we would unlock 
her secrets, we are to pursue her with singleness of purpose, and in our process 
be consistent with ourselves. If she ask for bread we would not give her a stone. 
It is the mistaken, the perverted, the unhallowed treatment she receives from 
some who call themselves her disciples, and the evils which afflict society from 
this source, of which I complain." — pp. 20-1. 

An indignant and high-toned lecture is then read to those who deny the profes- 
sion as one which keeps not pace with the improvements of the age in almost 
every branch of knowledge, and we are told, not ex cathedra, but with the proofs 
of the statement placed before us, that so far from this being the truth, those who 
will compare the amount of knowledge of a very recent period with that at present 
in possession of the profession, will be astonished with the strides it has made. 

" In short, the .practice of physic has participated in every improvement, it has 
advanced by every discovery, and enriched itself with every new truth fitted to its 
designs. The answer seeks no equivocation; skepticism may hesitate, but the 
disciples of Apollo remain unshaken in the great truth: the science of healing, 
embracing practical medicine and the chirurgical art, never fulfilled its sacred 
mission to the measure and extent of the blessed powers it now summons to its 
trust."— pp. 31-32. 

After some allusions to the improved statistics on which life-assurances are 
based, Dr. Francis says: — 

"I should not have dared to detain you so long to disprove the declaration, that 
the profession is behind the age, reluctant of improvement, fearful of new princi- 
ples, and contented with the knowledge of our forefathers. The utterance of such 
sentiments has often annoyed me, when I knew how hard we toiled to better the 
condition of the afflicted; what midnight cares absorbed us, what pains and penal- 
ties we endured, to become the successful prescriber; but this is not all: senti- 
ments like these too often proceed from the enlightened members of the most 
sacred profession ; and hence, actuated by the belief which such opinions sustain, 
they, with all their benevolence, superadded to the weight of their sacerdotal office, 
sustain theories, and give credence to alleged facts, which are often at war with 
the best established principles of medical science, and indirectly do harm to that 
calling which is like unto their own corporeal nature, demanding physical relief, 
as the immortal soul the support of divine counsel. There is not one among you, 
who is not qualified by experience to appreciate the bearing of these imperfect 
remarks; and sorry am I to say, that nothing other than my duty in discharge of 
the service I am summoned to perform, has led to an allusion to such occurrences. 
The Right Rev. Bishops of the Church of Great Britain, with their subordinates, 
who set forth in solemn testimony their convictions of the cures in diseases de- 
rived from Perkins' metallic tractors, humiliating as was the spectacle, impugned 
not the orthodoxy of their religious faith ; but it would be difficult to exonerate 
them from blindness in observation, and fallacy in judgment, in medical affairs. 
Pope Innocent II. forbade all the clergy to meddle with physic. He was wrong 
in the universality of his prohibition. There are intellects in that order of men, 
who, with profundity in the requisitions of their own vocation, add the precious 
treasures of the heart and of the head, and can scan the grounds of our practice 



1848.] Discourse before the N. Y. Academy of Medicine. 177 



however astute may be the doctor. Yet, on the other hand, there are examples 
which show us, that even in the priesthood, as in the profession of the law, some- 
times the most exalted in their specified pursuit are bad umpires in medical 
cases. 

" I well remember an interview I enjoyed with the late Rev. Dr. John M. Mason, 
the unrivalled preacher of this country in days past. He had repeatedly travelled 
abroad, and extensively visited Great Britain. He was asked why he did not give 
to the public the results of his observation. 'Alas!' he replied, 'what sort of 
travels can I write? T neither understand the nature of the air I breathe, nor the 
water I drink, nor the earth I tread upon: my life has been appropriated to po- 
lemical divinity.' The frankness of this answer was characteristic of this honest 
and great man, who long bore the name of the American Paul. But no more. I 
should feel deeply aggrieved if these recitals on the art of healing led any to sup- 
pose I was deficient in reverence to the ministers of gospel truth. They have 
too many points of resemblance in their career with our profession, not to excite 
our esteem and affection : their office is humanity; their service springs from the 
grandest principles of our nature. We meet, together, in season and out of sea- 
son, too often, the same objects of distress: we approach the same sufferer, and 
mutually commiserate his calamity; we are wearied in mind and in body by the 
same agonizing causes. We sympathize with each other in beholding the uncer- 
tain struggles of life with death ; we are actuated in the ministration of our offices 
by a like spirit of benevolence ; we know that our most certain recompense is our 
future reward ; for few doctors, as few divines, leave this world with more riches 
than they first entered it. Like offices, like impulses, like sorrows, like gratifica- 
tions, and like reflections endear us each to the other. These messengers of 
peace, to use the language of the Earl of Peterborough, are often most delicious 
creatures ; and if we be enamoured of our art, we will foster them as auxiliaries 
in our extremest need." — pp. 35-37. 

Without dwelling with the Doctor upon "the high requisition's both of the heart 
and head for the medical profession,'' requisitions which are essential to the suc- 
cessful pursuit of medicine, and which society has a right to make of those who 
offer themselves as practitioners, though public opinion has too frequently failed 
to recognize the essential moral dignity of the profession of which the "members 
are brought nearer to their fellow beings than any save those who have the au- 
thority of kindred," we pass on to where he shows that medical knowledge is 
identical with the progress of society, a position which he enforces with many 
apposite and striking proofs, and concludes this part of his discourse thus: 

"I think I hear the interrogatory, what inference is to be deduced from facts 
like these, and a thousand others of a similar nature, that might be accumulated 1 ? 
That medicine is a science so broad in its relations, that in every state of society, 
as at every period of life, it is called in requisition; that it is appreciated at a high 
standard by the humblest and the loftiest communities ; that the rude and uncivil- 
ized, the cultivated and the most refined nations, at the most elevated eras of their 
celebrity, have honoured the art and its professors ; that its disciples have been 
favoured with becoming consideration, wherever the arts, erudition and philoso- 
phy have found claims to regard : that it is a progressive pursuit; that it finds cir- 
cumstances favourable to its advancement in every stage of man's civil and politi- 
cal condition; that in its nonage, like the other sciences, it had its struggles with 
imperfections ; that in the most refined periods of social organization, its cultivation 
is most mature, and its culminating point at nearest approach." — pp. 47-48. 

After expatiating upon some of the promising features of their condition as in- 
habitants of New York, "from a conviction that a clear understanding of the ele- 
ments of life makes evident the responsibilities of the profession they have asso- 
ciated to elevate," he proceeds to devote the large portion of the remainder of his 
discourse to a series of very graphic and well -drawn memorials of some of the 
departed worthies who have graced and done honour to the profession in New 
York— many of them tributes of personal respect and genuine labours of love. 

The subject of medical improvement next receives, as it must that of every 
reasoning and candid physician, his hearty approval. 

" There are desiderata, moreover, indispensable to entire success, which pa- 
triotism calls aloud for, and which the profession invokes. If the physical condi- 



178 



Bibliographical Notices, 



[July 



tion and moral eminence of a nation depend upon the healthy scale and intellectual 
tone of its people, and there is a wonderful connection between them, then does 
it behoove our rulers to do more in furtherance of the acknowledged designs of 
our Universities and Colleges; to aid with a liberal provision in promoting the 
higher as well as the common branches of professional science. The apparatus 
in our institutions ought to be more ample, so that our youth may need nothing 
to give them the fullest measures in quantity and in quality of that wisdom which 
can be turned to the best and most appropriate results. They may go abroad 
empty, and they may return filled with the learning of the schools; I shall always 
honour them for efforts thus made in these their laudable endeavours for know- 
ledge' sake; but their efficiency as practical medical men is only to be secured by 
a proper course of study in their own land, by their becoming the observers of the 
diseases of their own climate, with the ethnological knowledge of those with whom 
they live and with whom they act. The sturdiest and most dexterous mariner on. 
the broad ocean, may find himself a cast-away in navigating his bark on the un- 
certain waters of our inland seas, or by an unwarrantable confidence in the spe- 
cious appearances of our mighty Mississippi. Climate has its diseases, and the 
topographical relations of a people will ever control their type and character. 
'The immediate and diversified effects of climate,' observes an eminent American 
writer, Prof. Smith, of the University of the State of New York, 1 are interesting 
to every class of persons; but to none is the study of its multifarious relations so 
important as to the student of medical science. Its direct influence in. producing 
and modifying diseases and its subsidiary effects, in giving energy to causes 
which otherwise would be inactive, should be subjects of special inquiry with 
every one who wishes to attain that knowledge which will qualify him to dis- 
charge his public duties, and elevate him in the scale of professional reputation.' 
\ The glory of Hippocrates,' he adds, 'was derived not more from his sagacity as 
a pathological observer, than from his knowledge of the character of diseases, as 
affected by the influences of air, water, and localities.' 

11 Far be it from me to depreciate the talents and the attainments of the facul- 
ties of other countries. I have some idea of their worth, admire their noble and 
humane efforts, and do homage to their labours: but I have scarcely ever seen a 
European physician who came among us, who had not many things to learn over 
again, and to abandon some of the most cherished doctrines in which he had 
been taught, ere he proved a successful general prescriber for many of the mala- 
dies endemial among us. Climate, soil, habits, and occupation, nay, the very 
government of a people, must be understood by the physician." — pp. 89-91. 

Dr. Francis then indicates some of the points that require careful and farther 
investigation, such as our native materia medica, cholera infantum, so terrible a 
scourge among us, but so little known in other countries, our endemical and epi- 
demical fevers, &c, and suggests that advantage might well be drawn from the 
study of the diseases of the brute creation. The alarming adulteration of drugs 
sold as genuine in this country, deserves strict investigation, and our greatest efforts 
to put an end to such an iniquitous proceeding. One other train of diseases de- 
mand assiduous study, " the mental diseases, or rather the whole class of mala- 
dies traceable to the intimate connection between mind and body," a study which 
the doctor argues forcibly upon the attention of medical men. 

Throughout this discourse, the various positions assumed are well reasoned, and 
illustrated with a freshness and vigour of intellect, which shows a mind constantly 
busied with the subjects on which it treats. It is truly able, and original, and 
shows in itself the advantages of the varied learning which it recommends. 

C. R. K. 



1648.] Dispensatory and TherapeuticaL Remembrancer, 179 



Art. XVIII. — A Dispensatory and Therapeutical Remembrancer, comprising the entire 
lists of Materia Medica. Preparations and Compounds, with a full and distinct ver- 
sion of every Practical Formula as authorized by the London, Edinburgh and Dublin 
Royal Colleges of Physicians in the latest editions of their several Pharmacopoeias : to 
which are subjoined copious Relative Tables exemplifying approved forms under which 
compatible medicines, may be extemporaneously combined, fyc. tyc. By John 
Mayne, M. D., L. R. C.S., Edinburgh. Revised, with the addition of the For- 
mulae of the U.S. Pharmacopoeia, by R. Eglesfeld Griffith, M.D. ; Sec. Lea 
& Blanchard: Philadelphia, 1848. 1 vol. 12mo. pp. 329. 

This work, as its very full title-page indicates, is a compendium of the British 
Pharmacopoeias, arranged according to a therapeutical plan, set forth alphabet- 
ically. It, of course, presents the formulae and directions of the three Colleges 
appertaining to Great Britain, and at a glance enables the reader to observe theii 
disagreement or conformity. The comparison of the three Pharmacopoeias, thus 
facilitated, must lead to the regret that a system of uniformity was not adhered to, 
or in other words, that by a convention or association of the wise pharmaceutical 
heads of Scotland, Ireland and England, one Pharmacopoeia was not framed 
which would better answer the purpose as a standard, and comport with the ad- 
vance of science. Where physicians are in the habit of prescribing as they must 
do, according to the standard of their locale, that of another, except in the way of 
curiosity, is of little importance to them. An Edinburgh practitioner expects his 
prescriptions to be compounded according to the Edinburgh Pharmacopoeia, and 
a London practitioner according to the London; there can be no choice in these 
places; if there be any exercised in favour of a better preparation, in a standard 
not his own, it is with some risk as regards strength, or considerable trouble to 
himself and the apothecary, who may keep but one preparation. A book of the 
present kind, then, we regard as an exposition of the absurdity of several standards 
in one kingdom, which evil we hope sooner or later to see abolished. 

Those interested in the perfection of pharmacy in the United States, have striven 
to attain uniformity, and by the publication of the United States Pharmacopoeia 
have obtained such a standard as required ; this has been engrafted on the present 
work, and thus we have four Pharmacopoeias presented to us between which to 
make a choice — truly a perplexing predicament, perchance, to him who is 
familiar with the merits of neither. Until uniformity be established, the necessity 
for a work, the motto of which should be e quatuor unum, may be sufficient to render 
the publication profitable, but we would rather see the excellencies of all more 
completely amalgamated, and the defects of all so eradicated as to present a work 
complete, perfect, and unhesitatingly authoritative. 

Besides a difference in the formulae, or rather in the quantities of substances which 
are used in the composition of preparations, as well as in the name employed to 
designate the same thing, a source of error lies in the disparity of the measures 
used by the several colleges. The Edinburgh and London employ the "imperial 
standard measure," the pint containing twenty fluidounces, while the Dublin and 
United States use the ct apothecaries or wine measure," the pint containing sixteen 
fluidounces. This is stated at page 286 of the work, and may be overlooked; 
In adopting one or the other of some formulae, an error of one-fifth in strength, either 
in increase or reduction may occur, if heed be not given to the standard measure 
of the authority directing the preparation. The tables of weights and measures 
should, we conceive, have been placed at the commencement. Conjoined with 
what Dr. Mayne claims as an originality, " namely, an unabridged practical 
formulary of the three British Pharmacopoeias; and this in addition to a full 
amount of collective information as to the use, &c. of the different medicines 
and other important points relating to remedial means and appliances," there is 
another novelty, which is the association of extemporaneous formulae, so placed 
under each head as to be distinct. The object of this is to show how articles and 
preparations may be combined and what are not incompatible. This is intended 
to be a help to prescribing and not a substitute for it, by presenting combinations 



180 



Bibliographical Notices. 



[July 



already elaborated to suit cases, the quantities of each ingredient not being indi- 
cated. 

A few pages at the end of the book are devoted to poisons, and their treatment. 

As in this little volume are presented four Pharmacopceias it will prove exceed 
ingly convenient for those who do not possess the originals, or who do not care to 
handle so large a work as the U. S. Dispensatory. To render it a little more so, 
we should have liked to see the translated Codex added. J. C. 



Art. XIX. — The Dublin Dissector; or, System of Practical Anatomy. By Robert 
Harrison, M. D., M. R. 1. A., &c. &c, Professor of Anatomy and Surgery in the 
University of Dublin. Fifth edition, Dublin and New York, 1847. 2 vols. 12mo., 
pp. 915. 

This much esteemed companion to the dissecting table has undergone complete 
revision, and comes to us graced with a variety of cuts which speak volumes to 
the eye of the student. The author is very happy in his descriptions, and we 
think has given the best account of the anatomy of hernia extant, the careful pe- 
rusal of which will amply repay the student. Much attention has also been given 
to the structure of the heart and its action, both of which are minutely described. 

In speaking of the arrangement of the air cells of the lung, he says (after stating 
that several anatomists believe that the air cells communicate with each other in 
clusters), " My own observations on this minute structure, not merely in man, but 
in many other animals, lead me to concur in this opinion," but he fails to give 
credit to Prof. Horner for first announcing this arrangement. 

So great a change has been brought about by the microscope, in the description of 
the central nervous system since the first edition of this work, that the terminology 
of the brain has been seriously altered, and it will be found that Mr. Harrison has 
kept pace with discovery ; and his description of the brain and spinal marrow con- 
veys a correct idea of the present state of knowledge on the subject. 

The only objection we have to the book is its form (in two volumes), which 
tends to diminish its usefulness. P. B. G. 



Art. XX. — The Young Stethoscopist ; or, The Student 7 s Aid to Auscultation. By 
Henry I. Bowditch, M.D.. one of the physicians of Mass. Gen. Hospital. 
Second edition. New York : S. S. & W. Wood, 1848, 12mo. pp. 304. 

Having already expressed our favourable opinion of this work on its first ap- 
pearance (see No. for July 1846), it is sufficient, in announcing a new edition, to 
state that the author has embraced the opportunity to make some additions, so as 
to bring it up to the present state of knowledge, and to correct some inaccuracies 
that accidentally crept into the first edition. It is an excellent elementary treatise, 
clear, precise and accurate, and may, as such, be strongly recommended to the 
student. 



Art. XXI. — On Bandaging and other Operations of Minor Surgery. By F. W. 
Sargent, M. D. Philadelphia: Lea & Blanchard, 1848. pp. 379. Small 8vo. 

The object of the author in preparing this volume is to furnish the young sur- 
geon and student with information relative to the art of bandaging, and the mode 
of performing some of the minor operations of surgery. The great importance of 
a familiarity with these subjects, is fully appreciated by every experienced sur- 
geon, and yet they are but cursorily treated in the systematic courses of lectures, 
and the student can only become acquainted with them by long attendance on a 
hospital, or by reference to some work especially devoted to them. Dr. Sargent's 
small volume is exceedingly well suited for this purpose. It is comprehensive in 



1841.] 



Elements of Natural Philosophy. 



181 



its plan, and the arrangement of subjects is judicious — the descriptions are clear 
and precise, and the wood-cut illustrations are numerous, amounting to 127, and 
most of them extremely well executed. 

The work is divided into five parts. The first embraces a description of the 
implements with which the ordinary duties of the surgeon are accomplished. 

"The second treats of the composition and preparation of Bandages, of their 
application to the different regions of the body, and of the purposes which they 
are thus made to subserve. 

"The third is devoted to the consideration of the apparatus of various kinds, 
used in the treatment of fractures. In the arrangement of this portion of the vo- 
lume, the author has thought it expedient to give pretty full details, showing the 
indications of treatment in each particular case of fracture, and thereby rendering 
more manifest the adaptation of each bandage, splint, or other dressing, to the 
fulfilment of these requirements. 

"The fourth division describes the mechanical means employed in the treat- 
ment of dislocations, with the mode of applying them. 

" In the fifth part are detailed at length the methods of performing such opera- 
tions as seem strictly to be included in the term " Minor Surgery :" these are the 
operations for bleeding, general and local ; the modes of effecting counter irrita- 
tion ; — the methods of arresting hemorrhage; the closure of wounds ; the introduc- 
tion of the catheter, and the administration of injections. A few remarks on the 
mode of relieving pain during operations, and a short appendix of useful formula?, 
close the volume.'' — p. viii. 

VVe can unhesitatingly recommend this volume as one of the very best of its 
class, and as furnishing a vast amount of information which it is essential for the 
young surgeon to know, in order to perform his daily duties with advantage to 
his patient, and satisfaction and credit to himself. 



Art. XXII. — Elements of Natural Philosophy : being an Experimental Introduction to 
the Study of the Physical Sciences. By Golding Bird, A. M., M D., F. R. S., F.L. 
S., Fellow of the Royal College of Physicians; late President of the Westminster 
Medical Society; Corresponding Member of the Philosophical Institute of Basle, 
of the Philosophical Society of St. Andrews, of the Medical Society of Ham- 
burgh, etc.; Assistant Physician to. and Professor of Materia Medica at Guy's 
Hospital. With three hundred and seventy-two illustrations. From the revised 
and enlarged third London edition. Philadelphia: Lea and Blanchard, 1848, 
12mo. pp 402. 

This volume is chiefly intended as a text-book for the student, whilst attend- 
ing lectures on physics, or as preparatory to his entering upon the study of larger 
or more elaborate works. Its compilation was suggested by the absence of 
any system of physics, sufficiently extended to include all those subjects with 
which men of education, especially members of a liberal and important profession 
like that of medicine, ought, and are required, to be familiar with; and at the 
same time, not too diffuse to disgust or weary the student. 

It is wholly unnecessary to discuss the importance of a knowledge of physics to 
the medical student. It teaches him the laws which govern some of the most 
important functions of animal organism, — explains the manner in which certain 
fractures, dislocations and various other surgical accidents are produced, and 
affords important suggestions as to the best mode of treating them. 

Dr. Bird's well digested and concise volume fulfils the object for which it was 
designed, and diminishes the regret we have long felt that Mr. Arnott should have 
abandoned his design of completing his admirable treatise on the same subject. 

Dr. B.'s work is divided into two sections. The first treats of the physics of im- 
ponderable matter, and embraces the following subjects: — Elementary laws and 
general statistics; general dynamics, simple machines; physics of liquids at rest; 
physics of aerial fluids at rest; general properties and laws of fluids in motion; 
sonorous vibrations of ponderable bodies. 

Section second i p devoted to the physics of imponderable matter, including the 



182 



Bibliographical Notices. 



[July 



subjects of — Magnetism; ordinary, atmospheric and voltaic electricity; electro- 
chemical decomposition; electro-dynamic induction; thermo-electricity; physio- 
logical electricity; light; optical apparatus and the eye considered as an optical 
instrument; heat, and photography. 

From this table of contents it will be observed that the scope of the work is 
very comprehensive, and that especially no subject of interest to the medical stu- 
dent has been omitted. 



Art. XXIII. — Principles of the Mechanics of Machinery and Engineering. By Julius 
Weisbach, Professor of Mechanics and Applied-Mathematics in the Royal Min- 
ing Academy of Freiburg. First American edition. Edited by Walter R.John- 
son, A.M., Civ. and Min. Eng., formerly Professor of Mechanics and Natural 
Philosophy &c. &c. In two vols., illustrated with one thousand engravings on 
wood. Philadelphia: Lea & Blanchard, 1848. 8vo. pp. 488. 

Chemical Technology; or, Chemistry applied to the Arts and to Manufactures. By Dr. 
F. Knapp, Professor at the University of Giessen. Translated and edited, with 
numerous notes and additions, by Dr. Edmund Ronalds, Lecturer on Chemistry 
at the Middlesex Hospital, and Dr. Thomas Richardson, of Newcastle-on-Tyne. 
First American edition, with notes and additions, by Professor Walter R. Johu- 
son, of Philadelphia. Illustrated with two hundred and fourteen engravings on 
wood. Philadelphia: Lea and Blanchard, 1848. 8vo. pp. 504. 

Though not medical works, we may be allowed to call attention to these vo- 
lumes, as they are devoted to the elucidation of subjects with which every man 
of education should be acquainted, and in the first named volume especially, the 
surgical student will find much information which he may turn to advantage in 
his practice. 

These volumes are numerously and most beautifully illustrated, and are issued 
in a style creditable to the enterprise and liberality of the publishers. 



1848.] 



183 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1 . On the Channels by which Urea is eliminated after the extirpation of the Kidneys. 
By MM. Bernard and Barreswil. — When the kidneys are extirpated in animals, 
urea accumulates in the blood; but several days pass over before any apprecia- 
ble quantity is present. The authors, supposing that during this period the urea 
must have some other channel of excretion, have analyzed the biliary and in- 
testinal secretions at different periods after extirpation of the kidneys in .animals. 
They find that, so long as the animal remains lively, the intestinal, and more 
especially the gaslric, secretions are increased in quantity, and, instead of periodic, 
become continuous; acquiring at the same time a considerable impregnation of 
ammoniacal sails. The subsequent diminution of the intestinal secretions, and of 
their ammoniacal ingredients, is accompanied by the first presence of urea in 
the blood, and the first symptoms of its poisonous effects. As the salts of am- 
monia are not normally constituents of the intestinal secretions, it is clear that 
this is a vicarious elimination of nitrogenous effete matter; and that the urea is 
secreted in substance by the intestinal mucous membrane and afterwards trans- 
formed into ammonia, is rendered highly probable by the fact, that chemically 
these substances are interchangeable, and that urea, when introduced into the 
stomach of a living dog, is always replaced by ammoniacal salts. — Monthly 
Journal and Retrospect of Medical Sciences^ April 1848, from Archives Generates de 
Medecine. 

2. On the Effects of the Introduction of Common Salt directly into the Stomach. By 
M. Bardeleben, of Giessen. — On introducing, by a fistulous opening through the 
abdominal parietes, a small quantity (45 grs.) of domestic salt into the empty 
stomach of a dog, a series of phenomena was constantly observed, which does 
not take place when the same quantity is taken by the mouth. Every part of the 
membrane in contact with the dry salt secretes very rapidly a nearly colourless 
mucus, varying in quantity. The stomach is then thrown into brisk contraction j 
the animal is agitated and uneasy, and is seen to swallow large quantities of saliva. 
The respiration is accelerated, and in four or five minutes vomiting is produced. 
After the vomiting has ceased, the gastric juice is frequently, though not invaria- 
bly, alkaline. This alkalinity of the gastric secretion is frequently met with in 
the empty state of the stomach, or even after the introduction of indigestible sub- 
stances, such as sponge or pebbles; but during digestion the secretions of the 
stomach are always acid. The above described action of salt is peculiar to it; for 
pepper, which is regarded as a much more irritating substance, is very well borne, 
and increases the gastric secretions without provoking any of those contractions 
and vomitings described. — Ibid. 

3. Non-absorption of Narcotic Poisons, (Prov. Med. and Surg. Journ., May 1848). — 
It has been established by numerous experiments, that when the circulation 
through a part has been interrupted, a narcotic poison introduced does not exert 



184 Progress of the Medical Sciences. [July- 



its specific action on the system. To account for this, three propositions have 
been advanced. 1st. That the poison is altered and rendered inert in the lymph- 
atics. 2d That it cannot enter them. 3d. That having entered, it cannot be 
conveyed by them. The first is opposed to facts; the second supposes a differ- 
ence between the structure of veins and lymphatics, which has never yet been 
demonstrated. The third hypothesis was advanced by Henle, who conceives 
that, like other fluids, narcotic poisons are taken up by the lymphatics, according 
to the general laws of permeation and imbibition, but that the poisons, acting on 
the coats of these vessels, destroy their irritability, and incapacitate them from 
conveying their contents. 

This hypothesis appears sufficiently plausible. The topical application of opium 
to the intestines destroys their peristaltic action. Aconite, infusion of tobacco, and 
other narcotic poisons, when absorbed from a wound, and carried by the circula- 
tion to the heart, paralyze this organ, and render it unable to contract on its con- 
tents. Finally, it can be shown that lymphatics, placed under the influence of a 
narcotic poison, are disabled from conveying into the system not only the poison- 
ous agent, but also inert solutions, which, under normal conditions, they absorb 
with facility. 

Mr. E. W. Day, of Birmingham, with a view of solving this question, instituted 
the following experiments, in which he exposed to the absorbing power of the 
lymphatics in the normal condition, and under the influence of a poison, two salts, 
both known to be readily absorbed by these vessels, and both susceptible of ready 
recognition in the secretions : — 

{Exp. 1.) The abdominal aorta of a middle-sized dog was tied below the 
origin of the renal arteries. Into a wound of the right hind extremity, near the 
foot, were now introduced ninety drops of a saturated solution of acetate of strychnia, 
followed by one hundred and twenty drops of a solution of iodide of potassium, 
(in the proportions of one drachm of iodide to one ounce of water.) In a similar 
wound of the opposite limb were introduced one hundred and twenty drops of a 
solution of ferrocyanide of potassium of the same proportions. After the lapse of 
two hours and a half, no symptoms of poisoning having appeared, sixty drops of 
the solution of strychnia were dropped into the wound in the abdomen. In ten 
minutes convulsions ensued, and the animal died tetanic. The bladder was re- 
moved, and the small quantity of urine contained in it received into a test tube. 
On the addition of a drop of solution of persulphate of iron, there at once appeared 
a bulky precipitate of Prussian blue, which presented a greenish hue, owing to 
the deep yellow colour of the urine. The fluid was filtered, the precipitate washed, 
and to the filtrate were added a few drops of chlorine water, followed by solution 
of starch. No change became apparent. 

{Exp. 2.) The abdominal aorta of a dog was tied. To a wound of the right 
hind foot was applied a mixture of thirty drops of hydrocyanic acid, (containing 
about forty per cent, of anhydrous acid,) with one hundred and twenty drops of 
solution of ferrocyanide of potassium. Into the opposite limb were introduced 
one hundred and twenty drops of solution of sulpho-cyanide of potassium, (con- 
taining one drachm in one ounce of water.) No sign of the action of the poison 
having appeared in two hours and a quarter, the animal was killed by introducing 
into the wound of the abdomen ten drops of the acid. The bladder was removed 
and the urine received into a test tube containing a few drops of solution of per- 
sulphate of iron. It immediately assumed a blood-red tint, but underwent no 
further change. To the fluid was now added a little sulphuric acid, and after the 
subsidence of a slight effervescence which ensued, a slip of pure zinc was intro- 
duced. In the gas which was evolved, sulphuretted hydrogen could be distinctly 
recognized by the odour, and a slip of lead paper was blackened by it. The fluid 
had now lost its red colour. 

{Exp. 3.) A third experiment w T as conducted in a similar manner. Into the 
right hind foot was introduced a mixture of one hundred and twenty drops of 
solution of sulphocyanide of potassium, with forty drops of prussic acid; into the 
opposite limb one hundred and twenty drops of solution of ferrocyanide of potas- 
sium. After the lapse of an hour and three-quarters, the animal having shown 
no indication of the action of the poison, was killed almost instantaneously by 
introducing into the wound of the abdomen a few drops of the prussic acid. The 



1848.] 



Organic Chemistry, 



185 



urine was received into a tube containing solution of persulphate of iron. A dis- 
tinct blue deposit left no doubt of the presence of ferrocyanide, whilst the unaltered 
colour of the supernatant fluid indicated the absence of the sulphocyanide. 

From these experiments Mr. Day concludes: 1. That strychnia and prussic acid 
cannot be conveyed into the system by the lymphatics. 2. That the non-absorp- 
tion of these poisons is due to a specific action exerted by them on the coats of the 
lymphatics, by which the irritability of these vessels is destroyed, and they are 
rendered incapable of transmitting their contents. 

From the dissimilarity in the operation of strychnia and prussic acid, it may be 
reasonably inferred, that most other poisons belonging to the same class will, on 
investigation, be found to conduct themselves in the same manner towards 
lymphatic vessels. 

4. Lymphatics of the Lungs. — Dr. Jarjavay has given, in the Archives Generates 
de Med., (Jan. and Feb. 1847,) a very elaborate account of the lymphatic vessels 
of the lung; he arranges them, for convenient description, into plexuses, and ves- 
sels properly so called, and these are superficial and deep. The superficial plexuses 
are spread upon the lung beneath the pleura; they present varieties in the form 
of the meshes, which are lozenge-shaped, or round, or variously angular, in the 
size of the vessels, and in the moniliform character of some. These last are 
chiefly those in the fissures, and the swellings on them are sometimes of consi- 
derable size, whilst the alternating narrow part sometimes impedes, or wholly 
stops, the flow of mercury through the vessel; this character is named varicose by 
the author, and the simpler condition is distinguished as capillary. It is common 
to find the capillary vessels occupying chiefly the surface of the upper lobe, and a 
portion of the lower, but the varicose, without exception, in the fissures and on 
the median face of the lung, especially about its root. The lymphatic plexuses at 
the borders of the lung, consist of straighter vessels, and are, in fact, the secondary 
trunks, which in turn discharge themselves in two or three principal vessels; 
these are, for the lower lobe, two constant and a third occasional ; they range the 
angles of the lung more or less parallel to it, and terminate in the bronchial lymph- 
atic ganglions. The "vessels" of the upper and middle lobes are more nume- 
rous; they occasionally dip under the surface, because they are overlapped by a 
lobule, but they always reappear; they assemble to terminate in the bronchial 
ganglions. It is worthy of remark that the black matter so constant in the lungs, 
has its seat in the track of the vessels of the varicose plexuses, and thus the pat- 
tern of these is mapped out by that black substance. Occasionally, pale lines 
mark out sundry black spots, these indicate swellings of the lymphatics, and it 
has often occurred to the author to inject the vessels by plunging his pipe into one 
of these spots. The deep plexuses are said to be those of the mucous membrane of 
the bronchi, but the author has failed to perceive their primary union with trunks. 
The deep vessels run between the large trunks of the bronchi and those of the pul- 
monary artery. To the question of how the lymphatics of the lung come into 
connection with those of the heart, and finally with the thoracic duct, the author's 
injections have failed to afford a satisfactory answer; he finds, however, that, for 
the most part, ganglions seated about the roots of the lungs receive the vessels, 
although he has noticed branches go directly to the thoracic duct, and in other cases 
join the diaphragmatic, oesophageal. &c. &c. The ganglions about the left bron- 
chus also receive the lymphatics of the heart, which reach them after following 
the curve of the aorta. — Report on Anat. and Phys.. in Ranking's Abst.. vol. vi. 



ORGANIC CHEMISTRY. 

5. Oxalate of Lime a Constituent of the Simplest Cellular Plants and of the Secre- 
tionofthe Mucous Membranes. By Dr. C. Schmidt of Dorpat. — In yeast, which had 
been left to itself for three weeks, the author observed the formation of a crop of 
beautiful crystals of oxalate of lime. By a series of careful experiments, he 
ascertained that this salt existed ready formed in the yeast cells, and could be 
extracted from them when perfectly fresh; and he concludes, from various circum- 



186 



Progress of the Medical Sciences. 



[July 



stances, that it must be dissolved in the fluid contents of the cell, as a compound 
of oxalic acid, albumen, and lime (oxalsaures albuminkalk) . 

As regards the elimination of oxalate of lime from the system, the author con- 
siders it impossible that, in the oxalic acid diathesis, it can be found in the stomach, 
experiment having shown that, when the oxalate of lime is swallowed, it is never 
found in the urine, the oxalic acid being oxidized in its passage through the system, 
and thrown off by the lungs and kidneys in the form of carbonic acid. He has 
never in any case found oxalate of lime, either in the saliva or gastric juice, but 
very frequently in the urinary sediments. Now, oxalate of lime is' totally insolu- 
ble in fresh urine, and as, from the structure of the secreting portion of the kidney, 
it is impossible for the urine to carry with it any insoluble matter, he infers that 
the oxalate must have a different source from the urea and uric acid, &c, of that 
fluid j and he concludes that it is a secretion of the mucous membrane of the kid- 
ney, and even of the bladder itself, from which it is probably thrown off in the form 
of the soluble compound above mentioned, and precipitated in the insoluble form 
by contact with the urine. In proof of this position, he points out that morbid 
increase of the vesical mucus is always attended by an increase in the oxalate of 
lime. That this salt is also found in the bile, where it is held in solution by the 
biliary mucus, and is precipitated when that substance undergoes decomposition, 
but not till then, as the bile does not, like the urine, possess the property of bring- 
ing it into the insoluble state. And lastly, which is his strong proof, he has in- 
variably found the oxalate of lime present in the mucous membrane of the uterus 
during pregnancy. — Monthly Journal and Retrospect of Medical Sciences, April, 1848, 
from Annalen der Chemie und Pharmacie. 

6. On the Variations in the Amount of the Phosphatic Salts in the Urine in Health and 
Disease. By Dr. Bence Jones. — " Mulder has shown, that in inflammation, one of 
the albuminoid constituents of the blood passes into a higher state of oxidation than 
that in which it usually exists. Oxides of protein, as he has called them, form 
the inflammatory crust. Indeed, the whole of the fibrin of the blood is changed 
into these substances. This alone would give us some reason for expecting, that 
in inflammations of particular organs, the constituents of these organs would be 
affected in a similar way. For example, that in inflammations of the brain, we 
should find the phosphorus of the phosphorized fats oxidized, forming phosphoric 
acid. 

"Now, after a long-continued experiment, which I have been enabled to make 
on the appearance of phosphatic salts in the urine, the result of nearly a hundred 
cases of disease, and of many hundred quantitative analyses, has been, that acute 
affections of the nervous substance, organic and functional, are the only diseases 
in which an excess of phosphatic salts can be proved to exist in the urine. By 
phosphatic salts, I do not mean the earthy phosphates alone, but the alkaline phos- 
phates as well as the earthy ones. I obtained and weighed not only the earthy 
phosphates, but the earthy and alkaline phosphates together — thus determining 
the total phosphatic salts present in the water. If it could be obtained, the water 
first passed in the morning was used for analysis; for I found it impossible to 
obtain, with any approach to accuracy, the whole quantity passed in the twenty- 
four hours. Had this been possible, it is probable that chronic diseases would 
have furnished me with positive results. 

" It was necessary, before beginning my experiments on disease, to trace the 
variations and their causes in the state of health. 

11 1. I found that the earthy phosphates varied soon after food from 1-91 per 1000 
parts of urine, specific gravity 1033-2, to -97 per 1000 urine, specific gravity 
1027-3. 

" Long after food, they varied from -75 per 1000 urine, specific gravity 1028-0, 
to -20 per 1000 urine, specific gravity 1028-2. 

"The alkaline phosphates, long after food, and soon after exercise, vary from 
8-10 per 1000 urine, specific gravity 1028-0, to 6-50 per 1000 urine, specific 
gravity 1022-8. Soon after food, the quantity varied from 6-67 per 1000 urine, 
specific gravity 1025-5, to 4-72 per 1000 urine, specific gravity 1033-2. 

"Sulphate of magnesia, chloride of calcium, or lime water, taken into the 
stomach, increased the earthy phosphates at the expense of the alkaline phos- 



1848.] 



Materia Medica and Pharmacy. 



187 



phates. After sulphate of magnesia had been taken as medicine, the earthy- 
phosphates were found to increase as high as 2-99 per 1000 urine, specific gravity 
1027-6; and in a second case, up to 2-93 per 1000 urine, specific gravity 1026-2. 
The amount of alkaline phosphates was found by experiment to be chiefly in- 
fluenced by the diet, and to a less extent by exercise. — Philosophical Transactions, 
1845. I then passed on to the amount of phosphates in disease. I found the 
variations in the earthy phosphates to be almost independent of the nature of the 
disease. 

11 2. In fractures of the spinal column, and in paraplegia, the total amount of the 
phosphatic salts was slightly above the healthy standard at the early period. When 
chronic, the total quantity of phosphatic salts was lower than natural. 

" 3. In some acute diseases, as acute inflammations and fevers, showed no in- 
crease. 

" 4. In some chronic diseases, as Bright's disease, dropsies, scrofulous diseases, 
exostosis, there was no increase. One case of mollities ossium presented a 
marked exception. 

11 5. In chronic diseases of the brain, and in chronic or even acute diseases of 
the membranes, there was no increase of phosphates. 

" 6. In fractures of the bones of the skull, when any inflammation of the brain 
supervened, there was an increase in the total amount of phosphatic salts. When 
there were no head symptoms, no increase of phosphates was observed, even 
though other acute inflammations supervened. 

" 7. In the general paralysis of the insane, no increase of phosphates was ob- 
served. Other insane patients presented nothing very remarkable. 

11 8. In acute inflammations of the brain, there was an excessive amount of 
phosphates secreted. When the acute inflammation became chronic, no excess 
was observable. 

"9. In some functional diseases of the brain, an excessive amount of phosphates 
was secreted ; this ceased with the delirium. In other cases of delirium, the 
phosphates were found to be greatly diminished." — Lancet, July 29, 1847. 

7. Urea in Normal Sweat. — Dr. Landerer has obtained a considerable quantity 
of urea from the flannel shirts of several persons who had been perspiring freely. 
In addition to urea, he has also obtained chloride of sodium, traces of sulphates, 
acetates and lactates, osmazome, and a substance soluble in ether. — Hellers 1 Ar- 
chives, vol. iv. 



MATERIA MEDICA AND PHARMACY. 

8. Proteine as a Medical Agent. — E. W. Tusson states (Medical Times, April 22, 
1848,) that he has prescribed proteine extensively with very beneficial results as 
a medical agent, and one calculated to produce a favourable termination in most 
cases of caries; also in some cases of scrofula, extensive ulcers, debility, diseases 
of the gums and teeth, rickets, undue lactation, and insufficient secretion of milk. 
In infancy, where debility exists, and where the functions are not duly carried on, 
and in some affections of the spine, five grains once or twice daily, will be suffi- 
cient for a child, and ten or twelve grains for an adult. He orders it to be taken 
as a powder, dry, or upon bread and butter. 

9. Aqueous Solution of Opium, acidulated with Muriatic Acid.— Dr. J. G. Nichol 
gives the following formula for this preparation of opium, which he says he has 
used for the last ten or twelve years, and extols as the best anodyne he has ever 
used. 

Take of the best powdered opium 33; muriatic acid § j ; distilled water 3XIX. 
Mix. Shake the mixture frequently every day during fourteen days, then strain 
and filter. The dose is from twenty to forty drops, according to circumstances — 
Med. Times, April 15. 

10. Iodized Oil. — This preparation has superseded the other forms of iodine at 



188 



Progress of the Medical Sciences. 



[July 



the Val-de-Grace. M. Marchal (de Calvi), reasoning from the fact of the virtues 
of cod-liver oil being due to the small portion of iodine it contains, concluded that 
a far more useful preparation of this substance than the iodide of potassium is 
found to be, might be made by combining it with an organic body. In this way 
a more complete assimilation of the substance, or, at all events, its longer reten- 
tion in the economy, might be secured. He chose an oily body, because this, 
forming an emulsion with the bile, would allow of the substance being digested 
in the small intestine, and enable the stomach to become relieved of its presence. 
In this way, far larger doses can be administered, if requisite, without irritating 
the latter organ ; while the iodine is eliminated by the urine much more slowly 
and in far less quantities than is the case with the iodide. The trials which have 
been made are very satisfactory in their results, the progress of the cure of buboes 
and other glandular enlargements being much expedited. The iodine is dissolved 
in fresh almond oil as wanted, in the proportion of 1 part to 15; and this is after- 
wards worked up into an almond emulsion. The minimum dose is one grain. — 
British and Foreign Medico- Chirurg. Review, April 1848, from Gazette des Hopitaux, 
No. 13, 1848. 

11. Tartrate of Potassa and Iron. By M. Mialhe — Although this compound, 
long known to chemists, has been but recently much employed in medicine, it 
possesses properties superior to most other martial preparations. Although it con- 
tains above 30 per cent, of the peroxide of iron, its ferruginous flavour is so slight, 
that it may be tolerated by stomachs which reject all other preparations of iron. 
It is very soluble, and as alkalies do not decompose the solution, it is as capable 
of absorption amid the alkaline juices of the intestine as in presence of the gastric 
acid. Moreover, it causes no constipation. It can, therefore, be well employed in 
all the pathological conditions demanding the use of iron, and especially such as 
require it in large doses, as the syphilitic cachexia. In a case related it changed, 
after long use, the colour of the hair from fair to dark, " a point well worthy the 
attention of physiologists and physicians, for it proves that, on the administration 
of iron, it is solely by the hairs that the excess of this metal is excreted, as M. 
Dumas had already supposed ; for certainly to sulphuret of iron was the colour 
due in this case." The drug has been said to give rise to diarrhoea, but this it 
does only when adulterated, which it very often is. Nothing, however, can be 
easier than for practitioners to prepare it for themselves, since for this it suffices 
to act upon an excess of peroxide of iron by cream of tartar, dissolved in six or 
seven times its weight of water, in the bath used for the preparation of extracts. 
As soon as the saturation is completed, which it is recognized to be by the deep 
red colour and the sweetish flavour acquired by the liquor, it is to be filtered and 
evaporated. The salt may be given in the form of pills prepared with mucilage, 
or, better still, with oily mucilage, which is composed of 200 parts of gum Arabic, 
100 of sugar, 100 of almond oil, and 250 of water, and by means of which the pills 
may be very rapidly prepared. From two to eight five-grain pills, or more, may 
be taken daily. Children will very readily take a syrup formed of simple syrup 
500 parts, the tartrate and canella water, of each 16 parts. — Ibid., from V Union 
Medicate, No. 2, 1848. 

12. External Employment of Belladonna — Mr. Donovan recommends (Dublin 
Medical Press, May 31, 1848) the substitution of atropa for extract of belladonna 
in liniments, as making a more cleanly and elegant preparation, and one of more 
certain strength. Atropa is very soluble in alcohol, although it requires five hun- 
dred times its weight of water for solution. The common belladonna liniment 
can therefore be prepared by dissolving two grains of atropa in four ounces of 
compound camphor liniment; the solution takes place instantly, and an elegant 
compound results. 

If an oily liniment is required, two grains of atropa may be dissolved in half 
an ounce of alcohol ; the solution has the property of dissolving castor oil, and 
forming a permanent solution; two ounces of it are to be added, and the mixture 
to be well shaken. 



1848.] 



Medical Pathology and Therapeutics. 



189 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

1 3 . Treatment of Phthisis Pulmonahs by Cod Liver Oil By Dr. Hughes Bennett.— 
The effect of the oil in many oases of phthisis is very striking, and is well seen 
in hospital and dispensary practice. Individuals presenting emaciation, profuse 
sweats, constant cough and expectoration, as most prominent symptoms, with a 
degree of weakness that prevents their standing alone, after a few weeks' use of 
it are enabled to get up with ease and walk about, with a visible improvement 
in their general health, and an increased amount of flesh. The physical signs 
of the disease may continue unaffected for some time; but if the treatment be 
continued, the moist gurgling r&les are exchanged for dry blowing sounds, which 
become more and more persistent, pectoriloquy is merged into bronchophony, 
the respiration is easier, and a check is evidently given to the ulcerative process, 
and the formation of purulent matter in the air-passages. In this state, patients 
often feel themselves so well that they insist on leaving the hospital, or give up 
their attendance on the dispensary. Dr. Bennett has frequently found it impos- 
sible to prevail on such persons to continue the treatment, and the consequence 
is, that, again returning to their often unhealthy employment and bad diet, and 
exposed to the other causes favourable to the production of the disease, the dis- 
tressing symptoms again recur. Several cases, with one or more caverns in the 
lungs, have in this manner returned to the Infirmary from four to seven or eight 
times during the last six years, and on each occasion have gone out in their own 
opinion perfectly cured. 

Notwithstanding the difficulties which have presented themselves in bringing 
about a complete cure of the disease, Dr. Bennett has succeeded, in several cases, 
in ascertaining that caverns have completely healed up, every symptom and phy- 
sical sign indicating their presence having disappeared, and only slight dullness on 
percussion, and increased vocal resonance remaining as a proof of the puckering 
and induration of the pulmonary parenchyma attendant on the cicatrix. He gives 
two unequivocal cases where this occurred, and alludes to others which he pur- 
poses publishing at some future time. 

Most cases of phthisis pulmonalis, especially in the advanced stage, are affected 
with more or less dyspepsia, which renders the stomach irritable, causes total 
loss of appetite, and is often the cause that prevents nourishment from being taken. 
In many instances there is no difficulty in employing the oil under these circum- 
stances, but in others it cannot be retained on the stomach. It will then be neces- 
sary to calm the irritability of the organ, and the best remedy for this purpose, 
according to Dr. B. ; s experience, is naphtha. It is to the power this substance 
possesses of checking vomiting, and thereby allowing nourishment to be retained, 
that he attributes the advantages which have attended its use in the practice of 
Dr. J. Hastings, and others. The diet should always be nutritive, without being 
stimulating; and counter-irritation to the chest is an excellent auxiliary. This 
treatment should be perseveringly persisted in; whilst, to prevent fresh exudations 
of tubercular matter, an equable temperature is of the highest importance. To 
equable temperature must be ascribed the advantages of favoured localities for 
phthisis, and with proper precautions it can be very well maintained in this cli- 
mate. — Monthly Journal and Retrosp., May 1848, from Bennett on Cod Liver Oil. 
Edinburgh, 1848. 

14. Case of very extensive Gelatiniform Cancer of the Peritoneum, involving the 
Lymphatic Glands of the Abdomen and Ovaries, and stimulating Ascites. By Edward 
Ballard, M. D.— A married woman, aged 55 years, became a patient under Dr. 
Ballard's care, at the St. Pancras Dispensary, on January 17th last. She stated 
that for twenty-seven years she had been subject to 'more or less epigastric pain. 
Between the ages of forty-five and fifty-two years she had suffered from an almost 
constant and very debilitating menorrhagia. At that time, also, there was an in- 
crease in the epigastric pain — which was occasionally relieved by an aperient — 
with the evacuation of mucus and membranous shreds, and a tumour was dis- 
covered beneath the margin of the ribs on the right side. In June, 1846, she 

No. XXXI.— July, 1848. 13 



190 



Progress of the Medical Sciences. 



[July 



slipped from some steps; a prolapsus of the wound followed, and she wore a 
pessary for three months. At this time the uterus ceased to prolapse, but she noticed 
the abdomen begin to enlarge, first at its lowest part; and she perceived a tumour 
in the hypogastrium, which, with that before detected, disappeared as the abdo- 
men generally increased in size. About Michaelmas, in the same year, she 
struck her abdomen violently against a post, since which accident all her symptoms 
had been aggravated, the enlargement continuing to increase. She began to vomit 
a few months previously to her admission at the dispensary. On being visited, 
she presented the appearance of a person labouring under some severe organic 
disease, and was considerably emaciated. The abdomen was greatly enlarged, 
dull on percussion generally, and fluctuating most distinctly; it encroached very 
much upon the limits of the thoracic cavity. The umbilicus was remarkable in 
being stretched and flattened out, and not prominent, as is customary in ascites. 
The case was believed to be one of ascites, arising from cancerous disease about 
the larger divisions of the portal vein, and under part of the liver; fibrous tumour 
of the uterus was detected, and encysted ovarian disease believed to be likewise 
present. She was tapped on the 24th, but only a teaspoonful of clear jelly passed 
from the trocar, and she died on the 26th. On examination of the body, the 
peritoneal cavity was discovered to be full of a firm and very tenacious gelatinous 
matter, emitting a very sickly odour. A large ruptured ovarian cyst, containing a 
similar matter, occupied the lower part of the abdomen ; and there were several 
smaller cysts about the inlet of the pelvis. The whole peritoneal surface of the 
abdominal wall and diaphragm was infiltrated with colloid cancer, as also was a 
considerable part of the peritoneal coat of the liver and spleen. There was a 
large tumour lying upon the right side, which was formed by the omentum and 
mesocolic glands converted into colloid ; and the mesenteric glands, with those 
about the under surface of the liver, were similarly affected. This diseased mass 
was connected below with a fibrous tumour of the uterus. All the gelatinous 
products, wherever found, presented the characteristic cells of cancer. (All these 
appearances were illustrated by preparations and drawings.) In commenting 
upon the case, the author introduced his remarks by observing that, although col- 
loid cancer of the peritoneum was not of very unfrequent occurrence, he had 
failed, in his search after a case at all approaching it as regards extent, and had 
been unable to discover another recorded instance in which colloid matter had 
been found free within the cavity of the abdomen. He believed that the disease 
had commenced in the mesocolic glands, from which it had spread upwards over 
the liver and spleen to the abdominal wall, and downwards to the omentum and 
ovaria; and that the general effusion of colloid into the peritoneal cavity had taken 
place subsequently to the rupture of the ovarian cyst from the blow the patient 
had received upon the abdomen. These opinions were supported by considera- 
tions deduced from the appearances after death, and from the clinical history of 
the case. Admitting the insufficiency of the grounds on which M. Cruveilhier 
maintained the malignant nature of all encysted ovarian disease, the author never- 
theless suggested that the opposite view of their nature would be found no less 
fallacious, holding that some forms at least deserved to be classed amongst can- 
cerous growths, and alluding to the discovery of cancer cells in his own case, and 
in ope which is reported as having occurred in the practice of Mr. F. Bird. He 
regarded the present case as establishing the possible existence of three forms of 
colloid cancer: — 1st, the ordinary locular form; 2d, the encysted (so named by 
Cruveilhier); and 3d, a free or unincluded form. He stated his belief that, in this 
instance, the plasma in which the free colloid was formed was only thrown out 
from such parts of the peritoneal surface as were in a state of disease. The paper 
concluded by calling the attention of the Society to two of the signs presented on 
physical examination of the abdomen ; one was the perfection of the fluctuation, and 
the other was the unusual condition of the umbilicus, which the author suggested 
might assist in the formation of a more accurate diagnosis, should a similar case 
ever again occur. — Proc. R. Med.-Chirurg. Soc. in Lond. Med. Gazette, March 1847. 

15. Pathological Nature of BrighVs Disease. — Dr. W. T. (5airdner ; in a paper 
read before the Medico-Chirurgical Society of Edinburgh, April 19th, maintained 
that the symptoms usually considered as indicating Bright's disease, are not found 



1848.] 



Medical Pathology and Therapeutics. 



191 



in connection with one pathological lesion exclusively, but may be the result of 
several disorganizing processes. The author described the pathological lesions of 
the kidney as being essentially the same as those of other organs, the differences 
being the result of the anatomical disposition of the gland. The deposition of 
fatty granules might occur in connection either with acute or chronic forms of dis- 
ease. Instances of its acute deposition are to be found in pneumonia, and other 
parenchymatous inflammations, where the so called exudation corpuscles have 
exactly the same mode of origin from the epithelium of the lung, as the fatty cells 
in the parenchyma of the kidney. Neither could the granular or fatty exudation 
be considered as the proximate cause of albuminuria or dropsy; as it might occur 
to a considerable extent without either of these consequences. Albuminuria was 
generally connected with imperfect formation of the secreting cells, and very 
frequently with desquamation, as described by Dr. Johnson, Mr. Simon, and 
others. Dr. Gairdner pointed out the analogy of this morbid process with the ordi- 
nary phenomena of mucous inflammations, as described by Henle. This he was 
disposed to consider as the initiatory process of Bright's disease; it might be suc- 
ceeded by exudation, or by other pathological lesions, according to circumstances. 
The granulated kidney, the non-granulated (fatty) kidney, and a peculiar waxy 
degeneration, corresponding with the " marbled"' kidney of Rayer, were described 
by the author as frequent in connection with Bright's disease. The result of most 
of these forms of disease was atrophy an<l contraction, which occurred by the ab- 
sorption of the exudation, and collapse and obliteration of the tubes. 

Dr. Hughes Bennett stated, that he had on several occasions examined the de- 
monstrations of Dr. Gairdner, and could vouch for the accuracy of the facts he had 
described. Some of those, more especially such as were explanatory of the changes 
occurring in the tubes after the evacuation of their fatty contents, were new, and 
constituted a valuable contribution to our knowledge of the morbid anatomy and 
pathology of renal disease. The observations of Dr. Gairdner. as well as those 
of several German pathologists, and of Dr. Johnson of London, as regards fatty 
degeneration of the organ, were illustrative of a series of changes which occurred 
in numerous glands, and exhibited the great importance of paying attention to 
accumulation of the fatty element as a cause of disease. There could be little 
doubt that exudation into the tubes was one of the primary changes in the kidney, 
whereby, as the author had explained, secondary effects were produced on the 
Malpighian bodies and the capillaries. It was in recent cases, more especially 
such as occurred during or subsequent to scarlatina, that fibrinous moulds of the 
tubes were most frequently found in the urine, which could only be regarded as 
the natural excretion of the morbid product. They were analogous to the fibrin- 
ous moulds of the bronchi, expectorated in pneumonia. Dr. Bennett considered 
that the good effects of diuretics in certain cases of kidney ^disease, might be 
explained by the increased secretion of fluid favouring the expulsion of these 
moulds. In other cases, again (which further observations could only more par- 
ticularly indicate), diaphoretics were of great service, owing apparently to the 
well-known sympathetic connection existing between the skin and all mucous 
membranes, but especially those of the kidney. 

Professor Simpson stated, that he was much interested in this subject from the 
frequency of albuminuria in pregnant cases. Disease of the kidney led to the 
absorption of urea, and a train of nervous symptoms of the utmost importance. 
He related several interesting cases of these, and especially one in which the urine 
remained albuminous for four months, and, after everything had failed, was cured 
by diaphoretics. The discovery of the fatty nature of the disease was very im- 
portant, and its frequent occurrence in cases of pregnancy might be explained by 
the circumstance, that milk was often secreted and circulated in the blood long 
before parturition. 

Dr. Paterson asked, whether the albumen found in the urine was secreted in 
the tubes, or was poured out from the blood, and how the hematuria, which was 
so common a symptom in Bright's disease, was occasioned'? 

Dr. Gairdner said, in reference to the remark of Dr. Bennett, that he had thought 
it right to be very cautious in drawing therapeutical inferences from a pathology 
which was still in its infancy. It had been attempted by some writers on this 
subject, to deter the profession from the use of diuretics in the desquamative forms. 



9 



192 



Progress of the Medical Sciences. 



[July 



of the lesion ; whereas these remedies were undoubtedly found useful in some 
cases, in which he believed their action was precisely similar to that of expecto- 
rants in catarrh and bronchitis. He had seen comparatively few cases of the 
temporary albuminuria described by Dr. Simpson, owing to his observations hav- 
ing been made in hospital practice. He considered the albuminuria undoubtedly 
a morbid secretion, and thought that the hematuria was generally seen where 
there was little of the fatty exudation. — Monthly Journal and Retrospect of Medical 
Sciences, May, 1848. 

16. On Certain Pathological Conditions of the Blood and Urine in Gout, Rheumatism, 
and Bright 1 s Disease. By Alfred B. Garrod, M. D. The object of the author's 
researches is to prove that — 

1st. In gout the blood always contains uric acid, and that this body can be crys- 
tallized from that fluid in the form of urate of soda. 

2d. That the uric acid is diminished or absent in the urine immediately preced- 
ing the gouty paroxysm. 

3d. That in patients subject to chronic gout with tophaceous deposits,* the urie 
acid is always present in the blood, and deficient in the urine, both absolutely 
and relatively to the other organic matters, and that the chalk-like deposits appear 
to depend on an action in and around the joints, &c, vicarious to the "uric acid 
secreting function" of the kidneys. 

4th. That the blood in gout sometimes yields a small amount of urea (no albu- 
men being present in the urine). 

Quantitative analyses and observations in favour of these conclusions were then 
detailed, and also the method used for separating the uric acid and urate of soda 
from the blood. Dr. Garrod thought it probable that the presence of a small amount 
of urea in gouty blood might be the cause of one of the symptoms which dis- 
tinguished gouty from rheumatic inflammation — viz., the slightly cedernatous con- 
dition of the inflamed part. 

The author next spoke of some experiments made on the blood of the sheep, 
and of birds. Sheep's blood was not found to contain uric acid, and even from 
the blood of the pigeon, whose urine consists entirely of that substance, none could 
be obtained. Human blood, from patients in tolerable health, was always found 
to yield a trace of uric acid, but a quantity exceedingly minute compared with the 
amount in gouty blood. 

The next researches were made on patients suffering from acute rheumatism, 
and it was found that rheumatic blood contains no more uric acid than the healthy 
fluid, and no urea can be extracted from it. Analysis made on the blood and 
urine in Bright's disease appeared to show that in albuminuria, 1, the blood 
always contains uric acid, but that the amount of this substance is subject to great 
variation; 2, that urea exists in large quantities in the blood, (which has been 
proved long since.) and that there appears to be no relation between the amount 
of the urea and uric acid ; 3, that the kidneys are always deficient in their power 
of throwing off urea, but that, with regard to the uric acid, their excreting func- 
tion is sometimes much injured, at other times little affected. 

In conclusion, the author thought that the results detailed in the communication 
led to the inference, that uric acid is not a product of the action of the kidneys, 
(as has been often supposed,) but that it is merely excreted from the system by 
these organs; also that the excreting function of the kidneys, for the solid portion 
of the urine, is not simple, but that the urea and uric acid are separately elimi- 
nated, and that one of these functions may be impaired or destroyed, the other 
remaining entire; it appears, also, probable that, as in albuminuria, the u urea 
excreting function being chiefly impaired, we find a vicarious discharge of this 
body in the dropsical effusions;' 7 so in gout the "uric acid excreting function" 
being defective, the tophaceous deposits are produced by a similar vicarious dis- 
charge of urate of soda. Gout would thus appear to depend on a loss of power, 
temporary or permanent, of the " uric acid excreting function" of the kidney ; the 
premonitory symptoms, and those also which constitute the paroxysm, arising 
from an excess of the acid in the blood, and the effort to expel this " materies 
morbi" from the system; an undue formation of this compound favouring the 
occurrence of the disease ; hence the connection between gout and uric acid cal- 



1848.] 



Medical Pathology and Therapeutics. 



193 



culous disease, and the influence of high living, want of exercise, &c, in inducing 
it. Thus also the hereditary nature of gout, and its frequent occurrence in low 
states of the system , can be explained — facts which are generally regarded as 
militating against the humoral pathology of the affection. The above researches 
appear also to remove acute rheumatism from gout, and to render it probable that 
they are only analogous in affecting similar structures. 

Dr. Ure stated that Berthollet had found the uric acid to become diminished in 
the urine previous to a gouty paroxysm: that some French chemist had found a 
considerable amount of phosphate of lime in some tophaceous deposits- and that 
he had noticed their crystalline composition. 

Dr. Williams expressed his gratification at the highly interesting and satisfactory 
results of Dr. Garrod's researches, which were the more important as establishing, 
on the basis of chemical demonstration, the true nature of gouty disease. It had 
long been a matter of high probability, that the ancient notion, that gout depends 
on a morbid matter in the blood, was correct; and many recent .observations on 
the causes, symptoms, and sequels of the disease, had led to the legitimate infer- 
ence, that this matter is lithic acid. This he (Dr. Williams) had learnt and taught 
for many years past. But the demonstrative proof, — the detection of this acid in 
the blood, — although often sought, had never been accomplished, and,;. to Dr. 
Garrod was due the entire credit of having first achieved that desideratum. The 
deficiency of lithic acid in the urine in the commencement of a fit of the gout, in 
common with other febrile movements, had been noticed by Berzelius; and its 
abundant reappearance on the decline of the paroxysm had been a matter of com- 
mon remark among practitioners. But Dr. Garrod's observation, that even when 
present in the blood, lithic acid is secreted in proportions varying from those of 
the other constituents of urine, was a fact interesting in a physiological as well as 
in a pathological point of view; although he (Dr. Williams) doubted that the ex- 
planation was such as the author suggested. He (Dr. Williams) thought that it 
would be taking too narrow a view of the origin of gout, to refer it to defective 
excretion only. Many facts had occurred to him which induced him to ascribe it 
also to imperfect assimilation, particularly of various proteinaceous nutriments of 
a low kind, (such as cheese, salted meat, and pastry,) which weak assimilative 
powers are unable to convert into blood, and which therefore decay into lower 
proximate elements. This corresponds with the experiments of Magendie, on the 
influence of azotized food in augmenting the animal matter in the urine; and Dr. 
Williams stated that he had in his own person experienced a proof in point, in 
finding some gouty symptoms invariably ensue after eating cheese for several 
days. On one other subject, Dr. Williams could not quite agree with the author,— 
that there is no pathological resemblance between gout and rheumatism. Prac- 
titioners generally acknowledge, that although in well-defined cases they are quite 
distinct, yet in others they appear to graduate into each other; and both in the 
copious deposits of lithic acids and its compounds, on the decline of acute rheu- 
matism, and in the unquestionable power of colchicum and alkalies in the cure of 
the disease, he (Dr. Williams) found a resemblance to gout, not to be effaced by 
the failure to detect an augmented quantity of lithic acid in the blood. In many 
cases of acute rheumatism, the state of the urine plainly showed that lithic acid 
was excreted in abundance, and a continuance of Dr. Garrod's researches would 
probably discover in the blood in this disease, if not lithic acid, something akin to 
it. and ready to be converted into it. 

Dr. G. 0. Rees had observed lithic acid to be absent in the urine in some cases 
of Bright's disease, which fact accorded with Dr. Garrod's detection of it in the 
blood. The circumstance of Dr. Williams having found solid urinary secretion in 
the cortical part of the kidney, in no way affected Mr. Bowman's theory, that such 
solids were secreted in the tubular structure. Mr. Bowman, when speaking of 
tubular structure, meant the minute tubular arrangement for secretion which ex- 
isted in the cortical part of the kidney, just where Dr. Williams said he had found 
the solid deposits of urine. These minute tubes were lined with epithelium, and 
were the continuations of the tubuli uriniferi as they approached the Malpighian 
bodies, and formed a considerable proportion of that part of the kidney called the 
cortical portion, as distinguished from the tubular, in rough anatomy. He (Dr. 



194 



Progress of the Medical Sciences, 



[July 



Rees) wished to ask Dr. Garrod in what cases of Bright's disease he had found 
the uric acid in the greatest amount. 

Dr. Garrod, in answer to the question of Dr. Rees, as to the cases of Bright's 
disease, or albuminuria, in which the largest quantity qi uric acid had been found 
in the blood, could state, that as far as his experience went, it appeared that the 
amount was greatest in cases of the acute disease, as those which arise after scar- 
latina or exposure to intense cold, the kidneys being in a state of congestion. He 
had also found it in large quantity in the last stages of the chronic affection, where 
the kidneys had almost lost their power of excreting at all. In the early stage of 
the last disease, he had often found that the "uric acid excreting ' function of the 
kidney was but little impaired. With regard to Dr. Williams' observations as to 
the relation existing between gout and rheumatism, he wished it to be understood 
that his analyses had been made on cases of the acute disease, as he considered 
that if any "materies morbi;" existed in the blood, it would be found in greatest 
abundance in such cases, and in these he had failed in detecting any such excess 
of uric acid. Hence, if the presence of uric acid in excess in the blood constituted 
its pathological condition in gout, then it would appear that the relation between 
the two diseases was not so close as had been considered by many. Dr. Garrod 
did not at all deny the existence of a "materies morbi;" he only stated that it 
could not be uric acid. He also wished it to be understood, that he did not con- 
sider the gouty paroxysm as depending altogether on the deficient excreting 
power of the kidney, for no doubt the increased formation of the morbid matter 
favoured greatly the disease ; perhaps, also, other matters generated in the stomach 
might, for a time, impede the excreting power of the kidney for uric acid; and 
hence the influence of sour beer, certain wines, and articles of diet, as cheese, &c, 
in inducing an attack. — Proceed, of R. Med. Chirurg. Soc. y in Lond. Med. Gaz., Feb. 
1848. 



17. On Albuminuria independent of Renal Disease. By Dr. Finger of Prague. — 
Among about 600 medical cases of various kinds in the general hospital at Prague, 
the urine was found to contain albumen in 155. Among these were — 

Tuberculosis, 



Typhus, 

Puerperal Fever, 
Carcinoma, . 
Chlorosis, 

Acute Rheumatism, 
Ague, 

Pneumonia, 
Pleurisy, 
Peritonitis, . 
Chronic Catarrh, . 
Diarrhosa, 
Disease of Heart, 
Epilepsy, 



186 


cases. 




\ 46 


88 


cc 




29 


46 


ti 




32 


14 


u 




6 


6 




.2 


2 


18 


cc 


.5 

'C 





10 


cc 


C3 

c . 


1 


33 


' *w * 





15 


14 


cc 




2 


6 


cc 




2 


16 


cc 


< 


3 


65 






8 


18 


cc 




7 


2 


cc 




2 



The remaining cases were 3 of chorea, 6 of paralysis, 2 of tetanus, and 3 of hyste- 
ria; in these no albumen was found. 

Of the 46 cases of tuberculosis with albuminous urine, 35 died; in 19 of these 
there had been cedema of the lower extremities, leading to a suspicion of granular 
disease of the kidney, which was nevertheless found to exist in 2 cases only. 

Of the 29 cases of typhus, 17 died; disease of the intestinal glands was present 
in all, combined in 2 cases with pneumonia; the kidneys were sound in all the 
cases. The albumen appeared in the urine generally from the 16th to the 25th 
day, while the disease was on the increase or at the height; in those which reco- 
vered, it uniformly declined and disappeared during the convalescence. 

The large proportion of cases in which puerperal fever was accompanied by 
albuminous urine, is explained by the admixture of the urinary and lochial dis- 
charges; in 6 cases, however, which were fatal from peritonitis, and in which the 
kidneys were sound, the albamen continued to present itself in the urine after the 
disappearance of the lochia. 



1848.] 



Medical Pathology and Therapeutics. 



195 



In 4 of the 6 cases of cancer, the albumen was evidently from the admixture of 
uterine discharges. The kidneys were sound in all. 

In 9 of the cases of pneumonia, the albumen disappeared from the urine during 
convalescence. In 6. which died, the kidneys appeared sound. 

Dr. Finger is disposed to conclude that, in cases like the greater part of the 
above, where albumen appears in the urine along with a fibrinous or purulent 
exudation into some organ of the body, it is in cotisequence of these exudations 
being re-absorbed into the blood, and evacuated as effete matter by the kidneys. 
In support of this view, he gives three cases where albumen appeared in the urine 
simultaneously with the formation of abscesses in different parts of the body ; and 
in two of which it was observed to disappear rapidly on the abscess being opened 
and the pus evacuated. 

Dr. Finger speaks strongly of the necessity of caution in the diagnosis of diseased 
kidneys from the presence of albuminous urine, where the evidence derived from 
the history of the patient is from any cause not conclusive. He narrates two very 
interesting cases of patients admitted to the hospital, with all the usual symptoms 
of cerebral disorder from retained urea, in whom there was also a large quantity 
of albumen in the urine; and which, nevertheless, after death presented no ap- 
pearance of granular kidney. In one there was slight puerperal peritonitis, and 
inflammation of the brain and its membranes, with two abscesses in the right 
hemisphere; in the other there were inflammation and purulent deposition in the 
urinary passages, with obstruction of one ureter and impediment to the function of 
the corresponding kidney, which was very much distended. In both these cases 
the diagnosis of Bright's disease, which was the one arrived at, was unavoidable, 
from the absence of any history of the patients' illness, and the state of insensibility 
on admission. 

In the two cases of epilepsy in which albuminuria was discovered, the albumen 
presented itself only after a convulsion, diminishing, and gradually disappearing, 
after the lapse of thirty-six hours. This observation is important m connection 
with the cases recorded by Lever and others, of the concurrence of albuminuria 
with puerperal convulsions. — Prdger Vierteljahrschrift, 1847, No. IV. 

[VVe consider Dr. Finger's observations as an important contribution to the pa- 
thology of albuminuria; at the same time, we cannot view his results as by any 
means clearly or definitely established. We are sure that no modern pathologist 
who has given any attention to the minute examination of the kidney, would be 
content to assume the soundness of that organ from the absence of the ordinary 
appearances of granular disease. Moreover, if Dr Finger's explanation of the 
albuminuria occurring during acute diseases be correct, how comes it that the 
albumen is present in the urine during the inflammation, when the fibrinous exuda- 
tion is at the same moment thrown out elsewhere; and absent during the resolution, 
at the very time when that exudation is re-absorbed into the current of the circu- 
lation. Further, we know, from the observations of Schonlein and others, that 
the effete fibrine of inflammatory exudation is generally converted, in passing off 
by the kidneys, into lithate of ammonia, which is deposited as a sediment soluble 
by heat; and. if this be established as the usual process, surely the secretion of 
unaltered albuminous matter by the kidneys, must be the result of some disturb- 
ance of their function. On the whole, we think it most probable, from the evidence 
before us, that the secretion of albumen by the kidneys, is generally the result 
either of functional alteration or of organic disease of the organ itself; and the 
researches of Dr. Finger are valuable and important, as tending to show the cir- 
cumstances under which this must readily occur as a temporary exudation, thereby 
presenting hints for present use in a diagnostic, and for future inquiry in a 
pathological,. point of view.] — Monthly Journ. and Retrosp., April 1848. 

18. On Ozone as a Cause of Disease. By Prof. Schonbein. — The experiments 
made by Prof. Schonbein some years since, tended to show, that when a current 
of ordinary electricity passes from pointed bodies into the air, a substance is pro- 
duced similar to that which becomes apparent, together with oxygen, at the posi- 
tive electrode on the decomposition of water by a voltaic pile, or by the action of 
phosphorus on moist air. To this substance the term ozone has been applied, as 
expressive of its powerful odour. The subsequent experiments of the same dis- 



196 



Progress of the Medical Sciences. 



[July 



tinguished chemist have further shown, that this remarkable substance is not only 
an eminently oxidizing agent, but that when inhaled, even if blended with a large 
quantity of air, it produces effects similar to those occasioned by chlorine and 
bromine; irritating the mucous membrane of the respiratory canals, and inducing 
acute catarrhal affections. As electricity is continually being evolved in the at- 
* mosphere, ozone must likewise be constantly produced in quantities which are 
probably proportionate to the intensity of the electrical discharges. As ozone at 
an ordinary temperature decomposes iodide of potassium by the separation of the 
iodine, it is evident that this iodide may, when mixed with a solution of starch, 
be used (if free from iodate of potash), for the purpose of detecting the presence 
of an infinitely small quantity of ozone in the atmosphere; since neither ordinary 
oxygen, nitrogen, nor a mixture of atmospheric air and carbonic acid, produces the 
same effect on iodide of potassium. This iodide paste will of course be coloured 
blue, with an intensity proportionate to the quantity of ozone present in the atmo- 
sphere. Professor Schonbein has found that the period in which the iodide paste 
turns blue in the open air varies extremely at different times; being occasionally 
coloured more intensely in a few hours, than at another period in the course of 
several days. On an average, this blue coloration is effected most rapidly in the 
colder seasons of the year; there are some days, however, during summer, in 
which the paste is very rapidly coloured, and this is especially the case in thunder- 
storms. Experience has shown that ozone is more rapidly produced by ordinary 
and voltaic electricity in proportion to the low degree of the temperature. It is a 
well-known fact, that in winter catarrhal affections of the mucous membrane of 
the respiratory organs frequently occur with such prevalence as to assume the 
character of an epidemic. Now if it were shown, that at certain periods, charac- 
terized by a general prevalence of catarrhal affections, large quantities of chlorine 
or bromine were present in the atmosphere, no one would hesitate to ascribe 
the cause of these diseases to the above substances. But it is an established fact, 
that by the inhalation of proportionally small quantities of ozone, physiological 
effects are produced similar to those which are occasioned by the inhalation of 
air charged with chlorine or bromine. This led Schonbein many years ago to 
conjecture that many catarrhal affections might be owing to the presence of ozone 
in the atmosphere. In the course of last winter, several catarrhal epidemics oc- 
curred in Basle, so that very few persons escaped; and Schonbein and many 
physicians of that town, instituted a series of daily observations, with the view of 
ascertaining how far the rapidity and intensity of the blue coloration of the iodide 
paste were connected with the prevalence and intensity of the catarrhal symptoms: 
the results were conclusive as to the simultaneity of the maximum of the coloration 
with extremest intensity of the epidemic. Further and more exact observations 
are, however, necessary for the establishment of this fact; and as an investigation 
of this nature may be so easily effected, we would call attention to the subject, 
which would be much elucidated by thermometrical and barometrical experiments 
(A simple method of making the observation, is by mixing pulverized iodide of 
potassium with a solution of starch, and exposing to the open air a strip of paper 
that has been rubbed over with the mixture.) As ozone is immediately decom- 
posed by sulphuretted hydrogen and sulphurous acid, it would not be wholly de- 
void of interest to determine, whether persons living in the neighbourhood of sul- 
phur-springs, or workmen engaged in metallurgic operations in which sulphurous 
acid is liberated, are less liable to catarrhal affections than those living in a purer 
atmosphere. In conclusion, we would remark that two hypotheses prevail with 
reference to the nature of ozone. According to Delarive and Berzelius, ozone is 
an allotropic modification of oxygen, occasioned either by electricity or by the 
catalytic activity of certain substances, (as for instance phosphorus;) whilst Prof. 
Schonbein regards it as a higher stage of the oxidation of hydrogen, the combina- 
tion of which is effected either by an electric or a catalytic influence. — British and 
Foreign Medico- Chirurg. Revievj, April 1848, from Henle u. Pfeuferh Zeitschnft fur 
rationelle Medizin, Bd. vi. Heft 2. 

19. Therapeutic Action of Cod Liver Oil By Dr. Hughes Bennett. — Dr. Bennett 
believes that the therapeutic action of the oil is dependent essentially on its being 
a fatty matter, perhaps more easily assimilated to the economy than any other 



1848.] 



Medical Pathology and Therapeutics. 



197 



kind of fat. He thinks the views of Ascherson fundamentally correct, with this 
difference, that instead of oil and albumen uniting to form elementary cells, they 
only produce elementary molecules and granules, from which nuclei and cells are 
formed. To him it seems certain, that in chronic rheumatism and tubercular 
diseases, the albuminous compounds are in excess, and the oily compounds are 
diminished in the economy. The direct addition of the latter, therefore, is the 
most rational method of supplying the wants of the system. 

It may reasonably be argued, that if the theory of its action as fatty matter be 
correct, any other kind of oil would prove just as serviceable, and certainly there 
are many much more agreeable to the palate. Experience, however, has decided 
this question in the negative. The reason of this probably is, that continued doses 
of the purest vegetable oils, as that of the olive and almond, are more or less pur- 
gative, and thereby diminish, instead of improving, the strength. It may also hap- 
pen that the pungent properties of cod liver oil may have a favourable influence 
in retaining it on the stomach, and rendering it digestible. Lastly, it seems rea- 
sonable that an animal oil should be much more easily assimilated to the system 
than a vegetable one. 

Since the publication of Dr. Bennett's work on cod liver oil, in 1841, the che- 
mical views of Liebig and others have come into notice, and it is a remarkable 
fact that they perfectly harmonize with the histological and morphological theory 
therein advanced. For, whether we regard the oil as a carbonized principle of 
the food, as furnishing an element for respiration, or as necessary to the formation 
of elementary granules in a nutritive blastema, it seems equally fitted to serve 
the end in view. 

That a purely chemical theory, however, is defective, is proved by the fact that 
every carbonized material is not fit for the purpose. We cannot produce an in- 
creased nutrition in rheumatic or phthisical constitutions by alcohol, sugar or starch, 
notwithstanding their chemical composition is so similar. The chemists may argue 
that these are converted into fats; and in the physiological condition so they are. 
In a pathological condition, however, when the digestive powers are enfeebled, 
this does not take place; and, in giving an animal oil ready made, we save the 
elementary organs the trouble, as it were, of doing this. Hence, in constitutions 
which cannot digest food, or convert it into the oily element, the introduction of 
cod liver oil, in large doses, causes the necessary principle easily to be imbibed 
into the lacteals, where, uniting with the albumen, it constitutes the elementary 
granules so necessary to nutrition. 

It is on this account, that in every disease of a rheumatic or tubercular nature, 
attended with impairment of nutrition, emaciation, weakness, &c, cod liver oil is 
directly indicated. It operates by imparting to the system one of the great ele- 
ments necessary for the nutrition of the animal economy, in cases where that ele- 
ment is essentially defective. In the hands of the rational practitioner, it is des- 
tined to be an important means of curing a class of diseases, hitherto considered 
of the most dangerous and fatal nature. As our knowledge of morbid processes 
improves, as the microscope and organic chemistry open up to us the primary 
alterations producing lesions of the body, the great importance of attending to the 
part played by the oily principle, as one of the essential elements of nutrition, will 
become apparent. Then, when pathology is made the companion of physiology, 
and both constitute the foundation for a rational system of therapeutics, the use of 
cod liver oil will be found as beautiful in theory as it has already been found be- 
neficial in practice. — Monthly Journal and Retrosp., May 1848, from Bennett on Cod 
Liver Oil, Edin., 1848, 8vo. 

20. Quinine in Intermittent Fever. — M. Bouchardat conceives that intermittent 
fevers may be usefully arranged under four forms or varieties, according to the 
intensity of the disease, and the corresponding effect of quinine on its course and 
duration. The first form includes those obstinate cases which require large doses 
(15 to 30 grains) of quinine for their temporary cure, but in which, in spite of the 
methodical use of the remedy, the fever continues to recur for years. This variety 
is found in Italy, North of Africa, &c, and is contracted, according to Bouchardat, 
by a lengthened residence in the neighbourhood of marshes, the water of which 
contains sulpho-salts in solution. To the second form belong those cases which 



198 



Progress of the Medical Sciences. 



[July 



require, but may be effectually cured by large dose? (15 to 25 grains) of quinine. 
An intermittent of this kind prevails at Tours, and has been, well described by M. 
Bretonneau, who observes that small doses are here insufficient. They habituate 
the patient to the action of quinine, irritate the stomach, and render it difficult to 
obtain the full action of large doses. The third form comprises those mild cases 
in which small doses (1 to 5 grains) are sufficient, not only to arrest the fever, but 
also to prevent its return. Lastly, he includes in a. fourth form, the numerous cases 
in which change of residence, or admission into hospital, is sufficient to remove 
the disease. — Gazette Medicate de Paris, Jan. 1848. 

[This classification of intermittents is certainly of considerable practical value, 
and serves to establish the principle, that the dissimilarity of action of the same 
remedy may indicate differences in diseases apparently identical occurring in dis- 
tant parts of the globe. The cases of intermittent fever observed in Paris and 
Vienna, belong to the third and fourth forms of M. Bouchardat. Thus, the prac- 
tice of Skoda of Vienna, which consists in giving three doses of quinine of two 
grains each, at intervals of one hour previous to the usual period of accession of 
the paroxysm, rarely fails to effect a cure in two or three days. On the second or 
third day he sometimes increases the third dose to four or six grains. The form 
of intermittent is, however, so mild, that we have repeatedly seen cases in other 
wards of the same hospital recover without any treatment whatever. On the other 
hand, the experience of physicians in Italy, Africa, and some parts of North Ame- 
rica, has shown that small doses of quinine are quite inefficient in the treatment 
of the intermittent fever prevalent in these parts of the world ] — Monthly Journ., 
May 1848. 

21. Double Pneumonia, — Hepatization of the Posterior Portions of the Lower and 
Middle Lobes of both Lungs, — Recovery. By W. H. Ranking, M. D. — A young gen- 
man, aged 17, of delicate frame, subject in infancy and childhood to repeated at- 
tacks of inflammatory croup, after exposure to cold was attacked March 22d with 
symptoms which were considered to indicate a common " bilious attack." It 
appears that he had some cough from the first, but this symptom was not so 
severe as to cause any anxiety on the part of his medical attendant until the 27th, 
when a sudden aggravation of the pulmonary symptoms induced him to seek my 
co-operation. 

When seen by me on the morning of the 28th, the patient was in the following 
condition: — Decubitus on the back, raised by pillows; countenance sunken, pale, 
and anxious; alae nasi in rapid motion; whole surface bathed in perspiration ; re- 
spiration 60 in the minute, abrupt and superficial ; pulse 130 to 140, feeble; cough 
slight; expectoration scanty, tenacious, and rusty. On raising him into a sitting 
posture, it was found that all the axillary muscles of respiration were in full play, 
and it was evident from the short and rapid breathing that a small portion only of 
the lungs was pervious to air. 

Physical signs. — Dullness on percussion of the posterior portions of both lungs, 
extending from an inch above the angles of the scapula on the left side, and 
about half an inch on the right; above these points, and over the anterior regions 
of the chest, the stroke-sound was normal, or nearly so; over the entire space 
indicated by dullness on percussion, the vesicular murmur was extinct, and in its 
place loud bronchial or tubular breathing was heard, the expiratory " whiff' 7 being 
peculiarly well marked. These signs were developed in their greatest intensity 
on the left side. In the upper lobes, posteriorly and in front, the respiration was 
puerile, but no crepitus could be discovered by the most attentive examination. 
The lower ribs behind were motionless. 

The above combination of physical signs, pointing out distinctly the existence 
of double pneumonia in the stage of hepatization, treatment to the best of my 
judgment, suitable to the emergency, was at once adopted. Six leeches were 
ordered between the angles of the scapulas as the only depletory measure admis- 
sible, and these were to be followed by a blister. The subjoined pill was also 
exhibited every two hours: — 

1£. — Hydr. chlorid. gr. ij; ant. potass, tart. gr. |; pulv. opii gr. i. Fiat Pilula. 
And eight grains of sesqui-carbonate of ammonia were given every four hours, in 
decoct, senekas. Beef tea ad libitum. 



1848.] 



Medical Pathology and Therapeutics. 



199 



29th. The leeches had bled well and the patient expressed himself as relieved 
at first by them, but at the time of our visit he was apparently all but asphyxiated 
by the sudden accumulation of bronchial secretions, which he was unable to ex- 
pectora'e. Suffocation appearing imminent from this cause, he was raised into 
the semi-erect posture, and brandy and water administered several times during 
the day. 

30th. Has expectorated a considerable quantity of frothy phlegm, under the 
stimulus of the brandy, and the immediate danger of suffocation has passed. The 
mucous rhonchi have also subsided as suddenly as they appeared. 

For the next two days there was no very obvious change, but it was evident 
that the patient did not lose ground, a matter, under the circumstances, sufficiently 
encouraging. Pergat. 

April 2d. General aspect improved ; respiration sank to 40, and the pulse to 
100; skin cool; tubular breathing less distinct, and vesicular breathing beginning 
to appear, especially on the right side. No 11 crepitus redux" heard, though care- 
fully listened for. As the bowels had been several times purged, and the motions 
were green, the calomel was replaced by mercurial dressing to the blister, and he 
had mist, creta. 

4th. Expresses himself as considerably better; scarcely any cough, and expec- 
toration scanty, but less tenacious, containing a small quantity of pus, and occa- 
sionally streaked with blood; gums tecoming tender; purging suspended. Both 
lungs '•' clearing up;" tubular respiration almost gone on the right side; still no 
crepitus. 

5th. Mercurial fetor well pronounced. The blister to be dressed less frequently. 
Ordered pulv. ipecac, gr. j; extr. conii gr. iv in pill, every six hours. To con- 
tinue the mixture. 

7th. Pulse 90; respiratory murmur heard fully to the base of the right lung; the 
left less permeable to air. 

12th. Has continued steadily to improve ; there has been but little cough or 
expectoration, but the respirations and pulse have gradually come down to the 
natural standard. Sits up and takes food with appetite. On examination of the 
chest, the left side is observed to be flatter than the right, and measures less by 
nearly an inch; it has a less extent of motion in breathing, but air may be heard 
to penetrate to the base, by causing the patient to take forced inspirations. Ordered 
potass, iodidi scr. j; vin. ferri oz. j ; infus. gent. oz. vj. Surnat cochl. magn. ter in 
die. 

From this period no regular reports have been taken, but occasional examina- 
tion has satisfied me that the left lung is gradually recovering itself, and the side 
expanding in proportion. He has now returned to his usual food and habits. 

Remarks. — The above case offers instructive evidence of what energetic medical 
treatment is able to accomplish, under apparently the most hopeless circumstances, 
and affords as triumphant an answer as could well be wished to those who would 
depreciate the efficacy of medicine, in order to magnify the restorative powers of 
unassisted nature. At the time of my first seeing the patient his vital energies 
were so much sunk, and the extent of lung rendered useless for the purposes of 
respiration so great, that I did not entertain the smallest hope of saving him, but, 
on the contrary, his death appeared all but inevitable — certain, if he remained 
many hours longer unrelieved. Pneumonia advanced to the stage of hepatization, 
and occupying a large portion of even one lung, is a disease of very considerable 
danger, and medical efforts are often baffled, although the patient possesses one 
sound lung for the maintenance of respiration. Here the major portion of both 
organs was rendered impermeable by air, and recovery must be looked upon as 
a rare, a fortunate event. Andral states that he has never known a patient recover 
from pneumonia, whose respirations reached fifty in the minute. In the present 
instance this number was exceeded, and they remained as high as forty for a space 
of two days. 

Two points especially worthy of notice, are the trifling amount of cough and 
expectoration, and the restoration of the lungs, without the reappearance of the 
<f crepitous rale." It is the not uncommon absence or trifling amount of cough, 
which causes pneumonia to be so often overlooked in its early stage by those who 
are not conversant with the practice of auscultation. An instance has occurred 



200 



Progress of the Medical Sciences. 



[July 



to me within the past year of one lung becoming almost universally solidified 
from pneumonia, which the medical attendant, an elderly practitioner, quite un- 
acquainted with auscultation, and occupied by a co-existing jaundice, had entirely 
failed to recognize; nor could T convince him of the fact, because there had been but 
little pain and cough in the earlier period of the attack. I saved this lady's life by 
at once commencing a vigorous mercurial treatment, but to this day I have reason 
to know the gentleman in question considers that the solidified lung was the off- 
spring of my imagination. 

The second point to be noticed, (the restoration of the hepatized lung without 
the reproduction of "crepitus,") is one of particular interest. From the time of 
Laennec till now it has been known, that when a portion of lung which has been 
solidified by inflammation begins to be restored, the crepitous rale which had 
disappeared as bronchial breathing becomes developed, again re-appears as the 
u crepitus redux." That this is the ordinary course of events is beyond dispute, 
and is alluded to by Watson, Williams, and, in fact, by every recent writer and 
lecturer on diseases of the chest. It may, therefore, be readily imagined, that I 
was not a little surprised to find that, though there was indisputable proof of 
amendment in the condition of the lungs of our patient, I yet could not on the 
most minute and repeated examination discover any " crepitus redux." The cha- 
racter of the breath-sound passed at once from the bronchial to the vesicular, the 
latter gradually gaining upon, and eventually displacing the latter. I could not at 
the time account for this, and was content to note it down as a fact, that " crepitus 
redux" is not an invariable accompaniment of the resolution of pneumonia ; when, 
upon turning to that admirable example of bed side teaching, Graves' 11 Clinical 
Medicine," I found the same fact had been observed by its author, and under 
precisely the same circumstances as were offered in the present case — viz., reco- 
very, with trifling cough, and little or no expectoration. Dr. Graves remarks, that 
in ordinary cases resolution of pneumonia takes place by increased secretion, 
together with interstitial absorption, but the latter alone is sufficient in certain in- 
stances. When such is the case, and no secretion takes place into the bronchial 
ramifications, there can be no £t crepitus redux." 

This case offers still another feature of interest, in the sudden occurrence of 
imminent suffocation from effusion into the larger bronchial tubes on the 29th. 
This effusion was evidently asthenic, resembling that which occurs towards the 
close of many other diseases. It might not have been of so much importance 
under some conditions of disease, but here it was a most formidable complication, 
obstructing what little portion of pulmonary tissue had been spared by the original 
malady. It was promptly met by the free exhibition of brandy, a few doses of 
which enabled the patient to discharge a quantity of frothy mucus. The urgent 
debility being thus obviated, the symptoms did not reappear. 

The treatment was conducted on general principles. Depletion to any extent 
was inadmissible, and it is questionable if free blood-letting is of use after he- 
patization has taken place, even if the patient's strength would tolerate it. All 
that is necessary in this stage, is by removing a small quantity of blood, to in- 
duce something like a balance between the bulk of the circulating fluid, and the 
diminished capacity of the lungs. I regretted even the application of a few 
leeches, in the present instance, and am not sure that they were not the cause 
of the sudden bronchial effusion above mentioned. It will be seen that mercury 
was looked to as the sheet anchor. Such I regard it to be in the stage of hepati- 
zation. The time is then gone by when good is to be expected from the use of 
large doses of antimony. The air-cells are clogged by fibrinous deposit; and the 
best absorbent of lymph, whether in the pulmonary tissue or between the layers 
of the cornea, is mercury. The iodide of potassium also did good service in 
completing the resolution of the obstructed lung. — Provincial Medical and Surgical 
Journal, May 17, 1848. 

22. On the Nature, Cause, and Prevention of Scurvy. By A. B. Garrod, M. D., 
(Monthly Journal of Medical' Science, Jan. 1848.) It appears from the various ac- 
counts that we have of scurvy, that although impure air, cold, moisture, age, and 
condition of habit, may favour the occurrence of scurvy, yet none of them, Dr. 
Garrod conceives, can be regarded as the real cause which must be sought for in 



1848.] 



Medical Pathology and Therapeutics. 



201 



the nature of the food. The causes of the disease, he says, are thus reduced' to 
one of the two following, viz : — 

1st. To the absence or deficiency of some organic substance in the food. 

2d. To the absence or deficiency of some inorganic constituent. 

Finding that all the theories of scurvy hitherto advanced were imperfect, Dr. G. 
was led to examine more minutely the composition of food under the use of which 
scurvy was capable of occurring, and also of such substances as had been proved 
beyond doubt to be anti-scorbutic, and afterwards to seek for the absence or defi- 
ciency of certain normal substances in the blood; and from such examinations he 
was led to the following conclusions: — 

1st. That in all scorbutic diets, potash exists in much smaller quantities than in 
those which are capable of maintaining health. 

2d. That all substances proved to act as anti-scorbutics contain a large amount 
of potash. 

3d. That in scurvy the blood is deficient in potash, and the amount of that sub- 
stance thrown out by the kidneys less than that which occurs in health. 

4th. That scorbutic patients will recover when potash is added to their food, the 
other constituents remaining as before, both in quantity and quality, and without 
the use of succulent vegetables or milk. 

5th. That the theory which ascribes the cause of scurvy to a deficiency of pot- 
ash in the food, is also capable of rationally explaining many symptoms of that dis- 
ease. 

Dr. Garrod gives the following table showing the amount of potash contained in 
several articles of diet. 

Grains. 

1 oz. of Baker's Best Bread (City), - 259 

1 oz. of Best Bread (West End), - - - - - - 257 

1 oz. of Home-made Bread, probably containing potato flour, - - 262 
1 oz. of Best White Flour, .- - - - - - 0-100 

1 oz. of Bran, - 609 

1 oz. of Rice, - - - - - - - 005 

1 oz. of Rice, - - - - - - - - 011 

1 oz. of Oatmeal, -------- 054 

1 oz. of Split Peas, - - - - - - - 529 

1 oz. of Raw Beef, 599 

1 oz. of Salt Beef, raw, - - - - - - 6-394 

1 oz. of Salt Beef.boited (slightly salted), .... o-572 

1 oz. of Boiled Mutton, - - - - - - - 637 

1 oz. of Dutch Cheese, - - - - - - - 230 

1 oz. of Boiled Potato of large size, - - - - - 1-875 

1 oz. of Raw Potato (small), ...... 1310 

1 oz. of Boiled Potato, without peel and well done, water containing much 

potash, - 0-529 
1 oz. of Onion (small), ------- 333 

1 fluid oz. of London Milk, ...... q-309 

1 oz. of Orange (not ripe) including septa, .... 675 

1 fluid oz. of Lime Juice, ------- 852 

1 fluid oz. of Lemon Juice, ...... 0-846 

1st. Potash is deficient in scorbutic diets. — Dr. G. shows that this is the case, by an 
examination of the dietaries of some workhouses and prisons, the inmates of which 
have become scorbutic. 

u In the diet of sailors," he observes, " we find abundance of meat (salted beef 
and pork) ; but no doubt the quality of these provisions is often much impaired 
by the prolonged action of the salt, causing the gradual exosmosis of the potash 
salts, and the substitution of those of soda. In an analysis of beef which has 
been exposed for only a few days to the action of brine, but where the thickness 
of muscle was not more than \\ inch, there was found to be a considerable 
diminution of the potash. One ounce of fresh beef gave 599 grains of potash, 
one ounce of salted beef 0-394 grains; and there can be little doubt but that a 
prolonged action of the brine would reduce very greatly the amount of potash 



» 



202 Progress of the Medical Sciences. [July- 

salts in the largest joints. So that the sailor's weekly dietary, when no vegetables 
can be procured, consisting of 9f Jbs. of salted meat, about 7 lbs. of flonr in the 
form of biscuits, and 1^ pints of peas, would contain about 90 grains of potash, 
suppo:>ing the meat such as stated above. 

"2d. That all bodies proved to be anti-scorbidic contain a large amount of potash. — 
All fruits contain this substance in abundance, as oranges, lemon, limes, grapes, 
gooseberries, &c, and these are all highly anti-scorbutic. Potatoes also, which 
perhaps are the most valuable as an addition to a dietary for the purpose of pre- 
venting scurvy, and owing to the scarcity of which article this disease has been 
so prevalent within the last two years, contain, as the above analyses prove, a 
very large amount of potash, and when boiled, (not too much, and unpeeled.) 
still retain most of that ingredient; this also accords with the fact, that potatoes, 
when cooked in the ordinary way, are anti-scorbutic, and at the same time ex- 
plains why the hard core of that tuber, which is so much liked by the Irishman, 
is most powerful in preventing the occurrence of scurvy, (see Dr. Lonsdale in 
Augur-t number of this Journal.) Milk, which is undoubtedly a good anti-scor- 
butic, and upon which the young of animals are for some time sustained, contains 
a very large proportion of potash salts compared with those of soda, being an 
exception to the relation between these two classes of salts which is found in the 
other animal fluids, — a pint of milk (London) and having a sp. gr. of 1-021. con- 
taining 6-180 grains. This was probably considerably diluted, as the usual sp. gr. 
is from 1-026 to 1 030. Berzelius's analysis gives about 9 grains; but the sp. gr. 
of the milk which he analyzed was much greater, about one-third. Fresh meat 
also contains potash in rather large proportion; and there is no doubt that ani- 
mals, such as the carnivora, living entirely on this substance in its uncooked 
state, take an amount of potash quite sufficient for the wants of the system. 
When we examine other articles noted for preventing or curing the disease in 
question, we find that potash enters into the composition of all in considerable 
quantities; this is true with regard to cabbages, turnips, onions, garlics, leeks, 
and hence their efficacy, and also of pickles and sour-krout made from them; the 
same is the case with the young tops of plants, as of the Pinus sylvestris, &c., 
when a decoction is made. Potash is also found in spruce beer, wort, malt 
liquors, wines, especially the lighter description, which contain this substance in 
the form of a bitartrate. but which becomes deposited in the stronger varieties. 

"3d. In scurvy the blood is deficient in potash, and the amount of that substance thrown 
out by the kidneys is less than whdt takes place in health. — A hundred grains of the 
dried serum of healthy blood, when incinerated and heated with the bichloride 
of platinum, gave 1-582 grains of the double chloride of potassium and platinum. 
A hundred grains of dried serum of scorbutic blood, treated in the same way, 
gave only 627 grains of the same salt; so that the amount of potash in scorbutic- 
blood was little more than one-third that contained in the blood in health, although 
the total amount of saline matters was nearly equal. In one case, a female, at 50, 
complaining of great prostration of strength, spongy gums, effusion in both ankles, 
&c, the amount of urine passed was 22^ fluidounces in the twenty-four hours — 
sp. gr. 1-015. Reaction very acid, and on standing, deposited mucus intermixed 
with uric acid crystals. The amount of potash excreted in twenty-four hours was 
much less than in health, being less than 7 grains; but a slight accident prevented 
a very accurate determination of the quantity. 

"In another case, the amount thrown out in twenty-four hours was 40 oz. Sp. 
gr. 1-010, and acid in its reaction. 

u 4th. Scorbutic patients, ivhen kept under a diet which gave rise to the disease, recover, 
when a few grains of potash are added to their food. — In several cases which came 
under my care, the treatment consisted in the daily administration of a few grains 
(from 12 to 20) of some salt of potash mixed with syrup and water. Sometimes 
the bitartrate, at other times the acetate, and also the carbonate and phosphate were 
used. All the salts appeared to act alike, and I have little doubt but the chloride 
of potassium would be found equally efficacious. When the cases were thus treated, 
all vegetables, milk, and malt liquors were strictly prohibited ; and yet the patients 
rapidly recovered. Other cases were treated by fresh vegetables and milk : these 
also recovered, but certainly not more quickly than those from whom these sub- 
stances were withheld, and potash salts substituted. On looking over the works 



1848.] 



Medical Pathology and Therapeutics, 



203 



of several writers on scurvy, I have frequently found that some potash salt has been 
administered with marked benefit ; thus, nitre has been recommended, nitre dis- 
solved in vinegar, the bitartrate of potash, the oxalate of potassa; but the efficacy 
has always been ascribed to the acid contained in these substances, and no atten- 
tion has been paid to the base. 

" 5th. The theory which ascribes the cause of scurvy to a deficiency of -potash in the system, 
is capable of explaining some of its symptoms — Both soda and potash are constant 
constituents of the animal body, and it appears that they are not capable of replac- 
ing each other; for example, we always find the potash to exist in large quantities 
in the ash of muscle, soda in very small quantities (Berzelius, Liebig): in the ash 
of ihe blood we find the relation reversed. It appears, also, that the muscular sys- 
tem requires the presence of potash, and we should therefore expect to find that 
where there is a deficient supply of this base, the effect would soon be manifested 
in the functions of that system. This we find to be the case in scurvy; without 
any amount of wasting of the body we find marked muscular debility, and this 
perhaps is one of the earliest symptoms of the disease." 

23. Tubercle and Cancer. — In the hospitals of Paris, Dr. Rognetta states (An- 
nates de Therapeutique, November 1847) the greatest mortality is owing to 
pulmonary tubercle and cancerous affections. Cancer is found wiih fearful fre- 
quency, in all its forms, in every region and in every tissue. It is an incurable 
disease, whether operated upon or not, and we are ignorant whether the most 
successful operation has ever retarded for a moment its natural termination. There 
is not even a general indication with respect to its treatment, and prescriptions are 
limited to opiates in every form, in the vain presumption that such remedies calm 
the pains. The disease, is incomparably less frequent in the centre of Italy, but 
instead, there are continually found severe affections of the arterial trunk, espe- 
cially spontaneous aneurisms, with general disease of the arteries, which often 
render operations inefficacious or insufficient. 

24. Free Communication between the Ventricles without Cyanosis. — Dr. Hare ex- 
hibited to the Pathological Society of London, April 17th, two cases of malformation 
of the heart. The subject of the first case was a child five months of age. The 
ventricles were hypertrophied without dilatation, and there was an aperture in the 
septum ventriculorum. 

The subject of the second was a child fourteen months old, the ventricles were 
slightly dilated and not hypertrophied; the foramen ovale was imperfectly closed, 
and there was imperfection of the septum ventriculorum. Notwithstanding the 
communication between the ventricles, there was no cyanosis. We are thus fur- 
nished with two more to the numerous cases already recorded, showing that the 
mixture of venous and arterial blood is not the cause of cyanosis. 

25. Erysipelas of the Hairy Scalp. By M. Grisolle. — Erysipelas of the hairy 
scalp without consecutive extension to the face is so rare a disease, that M. Chomel 
has not seen more than three or four cases during his long practice. An example 
falling recently under M. Grisolle's observation, he made a few remarks upon it. 
In this case the disease occurred without any previous injury or wound of the scalp 
whatever; and it offered a good example of a characteristic of the affection 
pointed out long since by M. Chomel, — namely, enlargement of the cervical 
glands. This is not a constant though a very common symptom, and precedes 
the occurrence of the erysipelas by two or three days ; and whenever M. Grisolle 
meets with it in an individual otherwise well, and suffering from no chronic 
affection of the head, or wound or erosion in the vicinity, he always prophesies 
the supervention of erysipelas of the scalp. In the present case, the earliest 
symptoms were a stiffness of the neck and an enlargement of these glands. 
These enlargements also occur in other affections, but then they do so consecutively 
only, and do not form, as in this erysipelas, a precursory symptom. It is of impoit- 
ance to attend to this, as erysipelas here manifests itself sometimes .only by very 
obscure symptoms. Pain and oedema of the scalp are, however, usually present, 
and redness may be seen by close examination. Vesicles never form on the scalp, 



204 



Progress of the Medical Sciences. 



the disease usually terminating by desquamation, which may be prolonged for 
several weeks. Numerous small abscesses sometimes appear at the close of the. 
disease. When the disease is traumatic, it may take on the phlegmonous form, 
and the case then becomes very serious. However great the detachment of parts 
this may cause, gangrene of the scalp never occurs; which Dupuytren explained 
by the fact of the vessels passing between 'the aponeurosis and the skin remain- 
ing uninjured amidst the destruction of the cellular tissue. Delirium is one of the 
symptoms most to be feared. It is, however, only sympathetic, and not due to 
inflammation of the brain or its membranes; for in the autopsies made in these 
cases by MM. Chomel, Louis, and Grisolle, no apparent lesions beyond a vivid 
injection of the scalp have been discovered. M. Grisolle predicted that the erysi- 
pelas in this case would not extend to the face, in consequence of the absence of 
the well-defined line and the red indurated border, which are always seen in 
erratic erysipelas.— B. and F. Med. Chir. Rev., April 1848, from VUnion Medicate, 
No. 14. 

26. Condition of the Gums in Phthisis. — Dr. Frederiq's attention was first called 
to this subject in 1844, when he observed a line of a red brick colour near the 
free edge of the otherwise normal gums of a phthisical patient. The line was 
very narrow, and ran parallel with the edge of the gums, but only opposite the 
incisors and canine teeth. Since that period, he has examined the gums in nume- 
rous subjects of phthisis, and has always found this red line more or less distinctly- 
visible, although sometimes only opposite the inferior median incisors. The re- 
searches of the author do not enable him to say whether this sign manifests itself 
as one of the earliest symptoms of phthisis, nor to declare absolutely that it is seen 
in no other disease, although he has never vet met with it in such. — Ibid, from 
VUnion Medicale, No. 5 7 1848. 

27. Laryngitis — [Mr. Parr communicated to the Surgical Society of Ireland, 
(March 4th,) the following interesting case of Laryngitis.] 

Case I.-— James Anderson, aetat. 30, a delicate-looking man, carpenter by trade, 
admitted into the temporary fever hospital under my care, about four weeks ago, 
labouring under pneumonia, for which I cupped, blistered, and mercurialized 
him. In the course of ten or fourteen days he was convalescent, the disease 
having terminated by resolution. On Wednesday, the 23d of February, upon 
visiting this patient, I found him complaining of some difficulty of swallowing 
from a sore throat. Upon examining the fauces, the velum and tonsils were found 
inflamed. There was no difficulty of breathing. For this I applied a few leeches 
to the angle of the jaw, and touched the surface with solution of nitrate of silver, 
and freed the bowels. The following day the symptoms were not relieved; the 
tonsils were slightly enlarged, the right presenting one small speck of ulceration. 
I Ipoked upon the case as one of cynanche tonsillaris, caused by exposure to the 
draught of a window which was near his bed. On the 25th I observed a slight 
stridor. Patient complained of increased cough and expectoration of frothy mucus 
during the night. 

Upon passing the finger into the throat, the epiglottis was found to be soft and 
erect, the voice raucid, and pain caused by pressure on the thyroid cartilage ; 
respiration laboured; pulse quick, and countenance anxious. 

Concluding the patient to be labouring under laryngitis, I ordered sjss of calomel 
immediately, to be followed every second hour by 2 grs. and gr. } of opium and 
4 oz. of wine. 

Upon visiting the following morning, my hopes of success from the mercury 
were disappointed by finding the patient had refused to take more than two 
doses of the medicine from the pain occasioned by swallowing. The symptoms 
were not relieved, but a very slight mercurial fetor existed. It was determined, 
in consultation with Dr. Brady, to give the mercury a fair trial, and so the small 
doses were repeated. At eight P. M., no appreciable amendment was discovered ; 
but as he stated he felt some relief, and fetor was more evident, the remedy was 
persevered in. About twelve that night, pytalism was fully established, dyspha- 
gia much diminished, and breathing considerably relieved. After this he fell into 
a sleep which lasted two or three hours, at the end of which period he awoke in 



1848.] 



Medical Pathology and Therapeutics. 



205 



a state of great exhaustion, from which he never rallied; and under which he 
gradually sank about five the following morning. 

Twenty-eight hours, after death, I examined the parts and found the mucous 
membrane of the fauces highly vascular, the uvula infiltrated, the epiglottis much 
thickened and inflamed, the rima glottidis reduced to a small slit, through which 
only the handle of the scalpel could be introduced. The mucous membrane of 
the trachea was highly vascular, presenting no trace of ulceration or adventitious 
membrane. 

Case II. — The next case is that of a girl, five or six years of age, who suffered 
from an attack of the epidemic, accompanied by some slight bronchitic affection, 
from which she was convalescing. On the 28th of February my attention was 
attracted by a peculiar hard cough, having the ringing sound, so characteristic of, 
and described as the harbinger of -croup. The little patient complained of no un- 
easiness, nor had she been observed to cough for some days previous. The pulse 
was not accelerated, nor was there any difficulty of breathing. Being fearful of 
an attack of croup, I ordered a solution of tartar emetic (one grain to the ounce), 
of which a teaspoonful was given every twenty minutes till it vomited, and then 
continued during the day in smaller doses. Low diet. 

29th. The medicine produced its emetic effects, and no further cough occurred, 
but a slight hoarseness remained. The medicine to be continued in smaller 
doses. 

About seven that evening, intense dyspnoea occurred, which threatened to carry 
off the patient. Four leeches were applied to the thyroid cartilage, and the tartar 
emetic increased. A large quantity of frothy mucus was ejected. The leeches 
bled freely, and greatly relieved the patient. About twelve the child was compara- 
tively easy, but did not sleep. Towards morning, the spasm increased, and upon 
seeing the patient at nine A.M., the breathing was most laboured, the child 
gasping, the diaphragm and intercostals acting powerfully, the lips were livid, 
and breath cold — in fact, each gasp appeared as if it would be the last. Dr. Moss 
and I concluded that there was no chance of saving the life of the child but by 
means of operation; so as quickly as I could procure the instruments, tracheotomy 
was performed at eleven. No blood of any amount was lost. Upon opening the 
trachea, great relief was experienced, the lividity partly disappeared, and the 
pulse became fuller. The patient was then wrapped in warm flannel, and placed 
in bed by the fire, being ordered one grain of calomel every hour, with a small 
quantity of wine. In twenty minutes after the operation, she fell asleep, which 
lasted about an hour and a half, when she awoke and asked for drink; almost 
immediately after, she began to sink, and died in ten minutes. 

From the foregoing cases, we must be particularly struck with the necessity of 
carefully watching all convalescents, whether from fever, pneumonia, or in fact, 
any disease which tends to depress the powers of life. 

The occurrence of laryngeal affections is by no means rare after fever, and the 
treatment of such more difficult, and the applications of antiphlogistic measures 
more hazardous than in idiopathic affections of the like nature. 

The rapidity with which this disease runs its course to a fatal termination ren- 
ders it imperative that something decisive should be done, and that quickly. 

Now, as to the application of the ordinary measures made use of in the treat- 
ment of this disease (occurring as a primary affection), the first of the foregoing 
cases indicates the danger of waiting for mercury to exhibit its specific influence; 
and the second, the inefficacy of tartar emetic to remove the mechanical obstruc- 
tion ; and thus where tracheotomy is finally had recourse to, tends to bring a good 
operation into disrepute. 

In one case, we have the mineral producing salivation (but at a late period), 
and thus relieving the symptoms, and holding out hopes of ultimate success ; but 
these were frustrated, in consequence of the low ebb to which the powers of life 
were reduced, by three causes — first, pneumonia; second, the secondary, or laryn- 
geal affection; and thirdly, the effect of the remedy, notwithstanding the use of 
stimuli. 

That the existence of mercurial action in the system does not modify the effects 
of inflammation, is evident, as this man was not entirely free from the action of 
the mineral when seized with the secondary affection. 
No. XXXI.— July, 1848. 14 



206 



Progress of the Medical Sciences. 



[July ' 



Another important point is exhibited in this case— namely, that the disease of 
such a fearful nature may assume at first an appearance of one of every day oc-. 
currence — in fact, it may commence as a common sore throat. 

Now, as to the propriety of performing tracheotomy in this case at an early 
period of the disease (notwithstanding the pre-existence of pneumonia), would 
that operation have afforded hope of ultimate success? I fear not. as the patient 
would have had to battle against bronchitis, which is almost a constant conse- 
quence of the operation. 

However, I proposed the operation, but as it was considered that mercury had 
not had a fair trial, so it was determined to persevere in its use so long as hopes 
of success could be entertained. The result we have seen. 

In the second case we see the fatal result follow the operation sixteen hours 
after the disease declared itself. The cause of failure in this instance is evident. 
Had the child had the benefit of the simple operation after the leeching and tartar 
emetic failed in affording permanent relief, T have no doubt it would have been 
successful. 

From these facts I argue that the frequent failure of tracheotomy, like the similar 
result after the operation for the relief of strangulated hernia, is due to that remedy 
being too long delayed, in order to make use of less certain means of cure. 

Mr. Parr has seen four cases of this disease, one of which was operated on by 
Dr. Porter, and recovered. In reply to a remark of Dr. ; Ryan, that he had seen 
in one of the French Journals scarifications of the rima glottidis recommended, 
Dr. Parr observed that the French had invented a sort of ring, of which he had* 
two or three sizes, which was passed into the mouth, and kept down the base of 
the tongue, so that by means of such an instrument, scarifications of the rima 
glottidis might be effected without much difficulty. — Dublin Med. Press. 

[A similar operation has been recommended by Dr. Buck in cedema of the 
glottis. See this Journal for Oct. 1847, p. 543.] 

28. Steracutine.—Dx. Verga Andrea, of Milan, read a communication to the 
Italian Scientific Congress, held at Venice, Sept., 1847, on a fatty substance of a 
greenish colour, sometimes passsd by children at the breast, and to which the 
name of steracutine was given some time ago by Prof. Semmola, of Naples, and 
the production of which the Prof, ascribes to the imperfect digestion of the buty- 
raceous portion of the milk. Dr. Verga's researches tend to elucidate the following 
points : — 

1. That children at the breast void such solid fatty concretions, when under the 
influence of certain diseases, is correct. These concretions are more or less 
rounded, transparent in their periphery, soft to the touch, insoluble in water, but 
soluble in alcohol. 

2. This substance is not voided by sucking children only; they have been seen 
at six and seven years old, and even in adults. 

3. Nervous diseases are not the only affections connected with it ; the author 
has observed it in measles and meningitis. 

4. This substance is almost exclusively composed of stearine ; and cholesterine 
exists in it in a very small proportion. 

5. There is no constant and regular connection between these evacuations and 
the progress of the diseases during which they may be observed. 

6. Like other excretions, this may prove critical and salutary, or it may be 
merely symptomatic, and of a bad omen. — Lancet, March 18, 1848, from L 'Union 
Medicate. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

29. Cases of Femoral and Popliteal Aneurism successfully treated by Compression. — 
A case of femoral aneurism cured by compression in thirty-three hours, by Staff- 
Surgeon Humphrey; and another of popliteal aneurism cured by compression in 
six days, by J. Tuffnel, Esq., with some very interesting remarks on these cases 



1848.] 



Surgery. 



207 



and on the advantages which compression possesses over the ligature in the treat- 
ment of aneurism, by Dr. Bellingham, are contained in the .Dublin Medical Press 
for Dec, 1, 1847. 

The subject of the first case was a soldier, 31 years of age, with an aneurism 
about the size of half an orange, at the lower third of the thigh, which had first 
been observed three weeks previously. At 12 o'clock on the 23d July, Read's 
aneurism compress was applied over the femoral artery of the groin, and the 
screw tightened so as to stop pulsation in the sac, and render the passage of the 
blood through the vessel imperceptible by the stethoscope. A clamp was loosely 
applied over the artery in the middle of the thigh, to be used when the pain from 
the instrument in the groin became too severe. In half an hour, the limb became 
slightly swollen, and of a darker colour, and its temperature fell. A flannel roller 
was applied from the foot to above the knee. In an hour and a quarter, the pain 
in the groin having become very intense, the instrument was relaxed, the clamp 
having been previously screwed sufficiently tight to command the circulation. 
About two o'clock (two hours after the first application of pressure), stinging pains 
began to be felt in the aneurismal sac and neighbouring part of the thigh, which 
became very tender to the touch. The point of pressure was changed every hour 
at first, but afterwards every twenty or tw T enty-five minutes, care being always 
taken to effect compression of the artery with the second instrument before relax- 
ing the other, in order to prevent a jet of blood into ihe sac. At nine in the eve- 
ning, the pain in the thigh being very severe, both instruments were loosened, and 
the part examined; the tumour was found to be much firmer, very painful when 
handled, and pulsated more feebly. An anodyne draught was administered, and the 
management of the instruments left to the patient himself during the night. 

2\th. The patient had no sleep from the pain in his thigh, and throughout 
the whole limb, which continued until three o'clock in the morning, and then 
gradually subsided. The tumour was considerably smaller and less painful, quite 
firm and solid, but still pulsated when the compressing instruments were taken 
off. The limb felt benumbed, and sensation was slightly impaired. Pressure 
was continued throughout the day by the two instruments alternately used. At 
nine in the evening, thirty-three hours after their first application, pulsation had en- 
tirely ceased in the tumour, the femoral artery could be traced to the sac, but no 
pulse could be felt in any of the arteries below that point, nor could the articular 
branches be felt about the knee. On the 25th, the use of the compressing instru- 
ment was discontinued. On the 4th Aug., the patient was discharged cured. 

The second case occurred in a sawyer, 27 years of age, of intemperate habits, 
who came under Mr. Tuffnell's care on the 3d of Nov., with popliteal aneurism. 
At 2 P.M., Nov. 3d, twelve ounces of blood of a highly carbonaceous character 
were taken from the arm, and a drachm of the compound powder of jalap ad- 
ministered. At six o'clock P.M., pressure was commenced, by means of Read's 
instrument placed upon the artery as it crosses the pubis, and the ring tourniquet 
at the lower third of the thigh, the pulsation being entirely checked, and the pa- 
tient taught how to alternate the pressure. This was borne till next morning at 
six A. M., when the pain became so severe in the limb generally, that he removed 
the instruments altogether. 

November 6lh. No alteration in the pulsation ; the patient slept at intervals, and 
the bowels were once moved ; pulse 78 ; and full. The same pressure was reap- 
plied. 

7th. The glands in the groin have become inflamed, and Read's instrument has 
been removed, the patient being directed to make pressure with his thumb against 
the pubis, and thus control the circulation, an assistant keeping his hand upon the 
tumour to ascertain the return of blood into it, and to direct increased pressure 
accordingly. The ring tourniquet was moved to the entrance to the canal in the 
adductors. At the evening visit, the leg was found to be oedematous, and the pa- 
tient complaining of numbness, which was removed by bandaging the limb with 
a flannel roller, and elevating it on a stretcher made for the purpose. 

8th. The pulsation has diminished, and the oedema is gone, the patient making 
no complaint. The ring tourniquet has been continued on the thigh, and pressure 
by a seven pound weight substituted for that of the thumb in the groin. Circu- 
lation has been arrested nearly all day. 



208 



Progress of the Medical Sciences, 



[July 



9th. Says that he has not slept, that there is much pain in the tumour, and that 
he dreads unscrewing the ring tourniquet from the increased pain occasioned by 
the jet of blood into the sac. Patient slightly feverish, and complaining of head- 
ache, but of no pain in the foot or leg. Almost constant arrest of circulation dur- 
ing the past twenty-four hours. 

10th. Using the ring tourniquet and weight; pain in the tumour diminished 
towards morning, when the patient slept, and awoke free from headache or thirst; 
says that he does not feel the blood jerk into the sac as heretofore, and that he 
does not now mind its influx. The clamps were substituted for the ring tourni- 
quet and weight — one being placed at the centre of Scarpa's space, the other at 
the commencement of the canal in the adductors. 

11th. Experienced much pain in the tumour and down the leg all the morning. 
At noon, whilst dozing, he was awakened by a sudden, acute, burning pain in 
the tumour and knee, which for two hours continued to be very severe. It then 
gradually subsided, On removing the pressure, all pulsation in the tumour had 
ceased. When visited at six, P. M.. the foot and toes were cold, but friction speedily' 
restored warmth, which was kept up by an extra flannel sock and roller. 

12th. Sac solid; not the slightest thrill through the tumour, and a large collateral 
vessel running down the centre of its surface; slight numbness only of the limb; 
its temperature natural ; compression continued for precaution's sake. 

13th. At the evening visit last night, the patient was found smoking a cigar and 
intoxicated. His debauch, however, does not seem to have produced any ill effect. 
All pressure was removed to-day, a bandage having been fastened to the heel of 
his sock and to a belt round the waist, so as to check and prevent the sudden and 
complete extension of the limb during sleep. 

The following remarks by Dr. Bellingham, who has been the ardent advocate 
of compression for the treatment of aneurism, are worthy of attention. 

u The two cases which have been detailed," he remarks. " bring up the num- 
ber of examples of popliteal and femoral aneurism successfully treated by com- 
pression, within the last five years, to thirty, in five of which the aneurism was 
seated in the femoral artery, in the remaining twenty-five in the popliteal vessel. 
Now, although a few cases may have occurred that have not been reported, it is 
obvious from the published cases that this mode of treatment has been, in a great 
measure, limited to Dublin. Thus from the London hospitals, only four cases have 
been reported, two by Mr. Liston, and two by Mr. Storks; five have been treated 
by military surgeons, including the two cases just read, this being the second which 
Staff-Surgeon Humphrey has treated since he has been stationed at the General 
Hospital, Phcenix Park; and two successful cases have been reported by naval 
surgeons; while all England, Scotland, and Ireland, with the exception of Dublin, 
have furnished within the same period but three other cases. 

" It can hardly be that popliteal and femoral aneurism are so much more fre- 
quent here than elsewhere ; but whatever may be the cause, it is obvious that if 
it be evidence of surgery having arrived at a more advanced state of perfection, 
where the necessity for operative proceedings is done away with, and a certain and 
safe method of treatment substituted for the knife (more particularly if the ope- 
ration is one very perilous to life), then the surgery of aneurisms must be con- 
sidered to have reached a higher state of perfection in Dublin than elsewhere, for 
during the last five years, but two cases of popliteal or femoral aneurism have been 
operated on in the "hospitals in this city ; and during the last three years at least, 
every case without exception has been treated by compression ; and of twenty 
cases so treated, eighteen have been perfectly and permanently cured; of the re- 
maining two, one, a patient of a broken-down constitution, died of erysipelas 
during the progress of the treatment; the other died of heart-disease shortly after 
the cessation of pulsation in the aneurism. 

'•'It has been repeatedly and frequently urged against the treatment of aneu- 
rism by compression, that it is not only a much more tedious procedure than the 
ligature, but that it is also much more painful. There can be no doubt that if this 
method is undertaken by a surgeon who is ignorant of the manner in which 
compression effects the cure of aneurism, — who does not understand how to 
regulate the compressing force, — who is not aware of the degree of pressure ne- 
cessary, or where to apply it most advantageously, — and who is not provided 



1848.] 



Surgery. 



209 



wiih the proper instruments for making compression. — the treatment will prove 
both tedious and painful, and we cannot wonder that it should fail in such hands; 
and the few cases which have been put forward with the object of deterring sur- 
geons from using compression, present a sad contrast in this respect to the. two 
just detailed. In Mr. Humphrey's case, for instance, compression for thirty-three 
hours was sufficient to cure the disease ; in five days, the patient was walking about, 
and in five more, he left the hospital, the use of the limb being perfect ; a period 
at which, if the operation had been performed, and everything had gone on satis- 
factorily, the patient would still have been exposed to the risk of ulceration of the 
artery and secondary hemorrhage. In Mr. TufTnell's case, in which the disease 
was of longer standing, the sac of a larger size, the patient of intemperate habits, 
having recently had the venereal disease, and the treatment conducted under all 
the disadvantages of a crowded lodging, where the regulation of the compressing 
instruments must have been left in a great measure to the patient himself, the 
treatment, notwithstanding, lasted only for six days, and the patient in that com- 
paratively short period was perfectly cured of a painful and dangerous disease. 
I cannot help, therefore, saying that any surgeon, with such poweriul evidence in 
favour of compression as these two cases afford, coupled with the previous evi- 
dence in its favour, who would expose his patient to the pain and risk of the ope- 
ration in popliteal aneurism, or in femoral aneurism low down, would, to use a 
mild expression, be exceedingly culpable. 

"There are one or two points connected with the foregoing cases worthy of 
further remark. The first is the relief from pain which the second patient experi- 
enced when the compressing instrument was applied, and the return of pain 
when the pressure was removed; evidently owing to the stretching and compres- 
sion of the parts about the aneurism being taken off when the blood was pre- 
vented from entering the sac in a full stream ; and showing that when an aneu- 
rism is large and produces much pain, compression really relieves this pain, and 
its application affords so much ease to the patient that he willingly maintains con- 
tinuous pressure. 

" The second is the occurrence of severe pain, and of an unusual character, in 
the parts about the aneurism at the period that the pulsation ceased. This fact 
has been frequently mentioned in the details of the cases of aneurism treated by 
compression hitherto recorded; it was very well marked in both the cases just 
read, particularly in the second. 

" I am of opinion that this pain is caused by the sudden enlargement of the col- 
lateral vessels, which ensues when the artery is obliterated at the point from which 
the aneurism springs, by which the neighbouring parts are necessarily also com- 
pressed, particularly the nervous twigs which accompany these arterial branches ; 
because this pain does not set in until immediately before the pulsation finally 
ceases in the aneurism ; because at this period we first detect pulsation in the 
articular arteries or other anastomosing branches; and because this pain subsides 
of itself after a time, as the new circulation becomes fully established. That the 
collateral vessels about the knee do not enlarge in popliteal aneurism until the 
aneurismal sac is filled up, and the artery at the part is about to be obliterated, is 
proved by their pulsation being detected first at this period : yet if we consult 
works upon surgery, we should be led to suppose that nothing was more easy 
than to bring about the enlargement of the collateral vessels ; indeed, compression 
was formerly recommended by writers on aneurism with this object, as a prelimi- 
nary step to the operation, by which they supposed the chances of success of the 
operation would be increased. But as the writers of the period to which I allude 
had not clear ideas respecting the mode in which the ligature effects the cure of 
aneurism, and were entirely ignorant of the manner in which compression brings 
about this result, we may be excused for not admitting their conclusions respect- 
ing the enlargement of the collateral vessels. 

" As there seems, however, to be still some misunderstanding or some difference 
of opinion with respect to the exact mode in which compression effects the cure of 
aneurism, I shall avail myself of the present opportunity to make a few observa- 
tions upon this point. 

"'It is obvious, first, that whatever mode of treatment may be adopted, unless 



210 Progress of the Medical Sciences. [July 

the sac of an aneurism becomes completely impervious to the entrance of blood, 
the disease will not be cured. 

" It is also obvious, secondly, that an aneurismal sac to be impervious to the 
entrance of blood, must become solid: that is, must be filled up with solid matter. 

" Thirdly, an external aneurism to be perfectly and permanently cured, must 
not only become solid, but the artery at the point from which it springs must be 
obliterated. 

" That these objects are fulfilled, as well when a cure is effected by compres- 
sion upon the artery between the aneurism and the heart, as when the ligature is 
successfully used, or when the cure has been brought about by nature's unaided 
efforts, 1 shall now endeavour to prove. 

" If we examine the sac of an aneurism where a spontaneous or natural cure 
has taken place, we find it filled with fibrin deposited in successive layers, the 
earliest or first formed being adherent to the interior of the sac, so as sometimes 
to appear almost to constitute part of its walls, and the succeeding layers in con- 
centric laminse, each within the other, until the cavity is perfectly filled. It is 
then completely impervious to the entrance of blood, and may be said to be cured, 
although the artery from which it springs preserves its channel unaltered. 

" I had the opportunity of exhibiting to the society last winter an aneurism of 
the thoracic aorta, which had undergone a spontaneous cure probably many years 
previously, and which illustrated these points remarkably well. 

" The consolidation of the sac being then the first and most essential step in 
the cure of an aneurism, and the deposition of fibrin in it being the process by 
which nature accomplishes this object, it is only reasonable to suppose that where 
artificial means are employed, they act by assisting nature in bringing about this 
result; we should therefore expect to find a similar condition of the parts after a 
cure by the ligature of the artery some distance above the sac, or after a cure by 
compression upon the artery between the aneurism and the heart ; and this is 
exactly what we do observe. 

" In the first case in which the femoral artery was tied for popliteal aneurism, 
the patient died of fever some months subsequently, and the opportunity was 
afforded for examining the condition of the parts; the sac was found to be solid, 
and filled with layers of fibrin. A drawing of the sac and of the artery is con- 
tained in the Philosophical Transactions, to which it was communicated by Sir E. 
Home. Many parallel cases are likewise scattered through the works of writers 
upon aneurism. 

" A patient who had laboured under popliteal aneurism, and had been sub- 
mitted to compression, but who died before the aneurism was cured, afforded me 
the opportunity of examining the condition of the parts. I found the sac of the 
aneurism in this case also nearly filled up by fibrin deposited in concentric 
laminse. The preparation was exhibited to this society last winter, and is now 
in the museum of the college. 

"Here, then, we have pathological evidence that the consolidation of the aneu- 
rismal sac is brought about in the same way, whether the disease be entirely left 
to nature, or whether it be assisted by art; and whether the artificial means used 
be the ligature or compression. 

"Now, it is hardly necessary to observe, that in cases where a natural or spon- 
taneous cure of aneurism takes place, the fibrin which fills the sac is deposited 
by the blood which circulated through it; there is no stagnation of the blood, no 
coagulation of it here; indeed the regular order in which the laminae of fibrin 
are arranged, prove that they must have been deposited by a current of some 
kind. It is evident, therefore, that if, on examination of an aneurism, some time 
after its cure by the ligature, we find the sac filled with regular concentric laminae 
of fibrin, a current of blood must have continued to pass through it subsequent 
to the employment of the ligature. It is equally evident also that if the same ap- 
pearances are observed after the use of compression, a current of blood must in 
this case also have passed through the sac until it became filled and consolidated. 

"The conclusions, then, to which we are necessarily led by the foregoing con- 
siderations are, that it is essential to the consolidation of an aneurismal sac that 
a current of blood should pass through it. Both the ligature and compression, 
therefore, would appear to act merely by assisting nature to accomplish, within a 



1848.] 



Surgery. 



211 



comparatively short period, what otherwise would have occupied a long time, or 
which, owing to a number of disturbing circumstances, she might never have 
been able to accomplish. 

" In order, however, that the cure of external aneurism should be permanent 
(no matter by what manner it is brought about), it is essential that, in addition to 
the consolidation of the sac, the artery itself should be obliterated at the point 
from which the aneurism springs. This is a point which has been in a great 
measure overlooked, and it is one of which we find no satisfactory explanation in 
works on aneurism. 

"Thus in all the cases in which the opportunity has been afforded for examin- 
ing the condition of the parts a long time after the employment of the ligature for 
popliteal aneurism, the artery has been found to be obliterated at the site of the 
aneurism as well as at the site of the ligature, while between these two points the 
channel of the artery is preserved. In the only instances in which the opportu- 
nity has been afforded for examining the condition of the parts some time after 
the cure by compression of popliteal and femora] aneurism, the artery was ob- 
literated at the point from which the aneurism sprung, and only at this point. In 
the cases which have been detailed by the older writers, where external aneurism 
underwent a spontaneous cure, and where the parts were examined subsequently, 
the artery was also found to be obliterated at this point, and at this point only * 
and the appearances were precisely similar to those found after the use of com- 
pression. 

" These facts, then, render it still more probable that the mode in which compres- 
sion and the ligature act in bringing about the cure, is the same as that by which 
nature accomplishes this object— viz., by the deposition of fibrin continuing after 
the consolidation of the sac, until the artery, at the point from which the aneurism 
springs, is also filled. 

" It is still supposed by some surgeons that pressure upon the artery between an 
aneurism and the heart, acts by causing the coagulation of the contents of the sac. 
Now if ; for argument's sake, we suppose that compression cures aneurism by 
developing a coagulum in the aneurismal sac, how are we to account for the ob- 
literation of the artery at the point from which the aneurism springs'? How are 
we to account for the disease never having returned in any of the cases successfully 
treated in this city'? How explain the non-occurrence of suppuration in the sac in 
any of these cases'? 

£< If, by means of compression upon the artery at the cardiac side of an aneu- 
rismal sac, we could coagulate its contents (which is highly improbable), the ar- 
tery would not be obliterated at the point from which the aneurism sprung, pulsa- 
tion would return in the sac, and the disease would reappear, or suppuration in 
the sac would be likely to ensue, the coagulated blood acting as a foreign body, 
and the frequent handling of the sac contributing to this result. The fact of the 
disease having been permanently cured in every case in which compression has 
been employed in this city affords evidence (even if we were without pathologi- 
cal proofs), that the coagulation of the contents of the sac was not the agent in 
effecting this ; while the circumstances under which pulsation has returned after 
the employment of the ligature, or suppuration has ensued after the operation, 
confirm what I have already said. 

" When either of the foregoing accidents follows the ligature, it generally de- 
pends upon the vessel having been tied so close to the aneurismal sac that the 
blood is completely cut off from it, no current passes through it, and no fibrinous 
layers can of course be deposited ; the blood, which finds its way into the sac 
after the operation, coagulates there; consequently we can hardly be surprised at 
a secondary aneurism forming under such circumstances, or that suppuration in 
the sac should ensue if the tumour is much or frequently handled. In the ma- 
jority of cases, the ligature being applied at some distance above the sac, the 
blood soon finds its way into it by the anastomosing vessels, a feeble current 
passes through it, the fibrin is detached and deposited upon its lining membrane, . 
and the cure is eventually brought about exactly as when nature effects a spon- 
taneous cure, or when compression has been used ; the cure is necessarily perma- 
nent, too, for the reasons stated, and suppuration of the sac never ensues, because 
fibrin, unlike coagulated blood 3 does not act as a foreign body. 



212 



Progress of the Medical Sciences. 



[July 



" I have delayed upon those points here because I find that some surgeons are 
of opinion that by using and keeping up strong pressure, they will bring about 
the coagulation of the contents of the sac, and they expect in this way to effect a 
cure with greater rapidity. If this object could be effected by compression, it 
must be by a different mode from that which has been hitherto used. To produce 
this effect, in fact, it seems to me that it would be necessary to apply the pressure 
to the artery immediately above and immediately below the sac, and to maintain 
this so as to prevent any disturbance of the contents of the sac until the blood 
contained in it coagulated. But even if this could be accomplished, it may be 
gathered from what I have said that it would not be at all desirable to do so, as the 
patient would be then liable to a return of the disease, or to the accidents to which 
I have alluded. When strong pressure is used, so as completely to interrupt the 
circulation in the artery at the part, it merely acts by permitting a very trifling 
stream of .blood to pass through the sac ; and whether the pressure be strong or 
moderate, the cure of the disease seems to be effected in the same way, 

"As there is a great difference in different individuals in the sensibility to pain, 
we may of course use stronger pressure, and continue it for a longer period in 
one subject than another - and a cure will of course be more quickly accomplished 
in a patient who can bear continued pressure for a considerable time, than in one 
* who is so little tolerant of pain that he removes the instrument, or relaxes the 
screw the moment the surgeon is out of sight; and this seems to be one of the 
circumstances which has most materially influenced the duration of treatment in 
the several cases hitherto recorded. 

"The pathological evidence which has been adduced, combined with pheno- 
mena observed during the progress of the treatment of cases of aneurism, all 
tend to prove that the cure of the disease is effected in one and the same way, 
whether the ligature is used, whether compression is employed, or whether the 
cure is brought about by nature's unaided efforts. It may therefore induce sur- 
geons to look with more favour upon compression as a mode of treatment, if they 
will bear in mind that, when they place a ligature upon an artery for aneurism, be- 
fore a cure can take place, the artery of the limb must be obliterated at two points 
of its course — viz., at the site of the ligature and at the site of the aneurismal sac; 
and this must be accomplished within a comparatively short period, or secondary 
hemorrhage will ensue from the wound, or a secondary aneurism will form at the 
site of the sac. We can hardly be surprised, therefore, that so many accidents sur- 
round the operation, and the amount of success which has hitherto attended it only 
proves the unbounded powers of nature. Indeed, as the circulation of a limb 
must be with some difficulty maintained, when the artery which supplies it is 
obliterated at two points of its course, we cannot be surprised at gangrene super- 
vening upon the operation in a case where the aneurism has been allowed to 
attain a very large size, by which the anastomosing vessels are compressed or 
prevented from enlarging, and by which the return of the venous blood from the 
parts below is interfered with. 

" On the other hand, when compression is employed, the artery is eventually 
obliterated at one point only in its course: the treatment is altogether unattended 
by danger; there is no risk of secondary hemorrhage; none of the formation of 
a secondary aneurism: while it possesses this great advantage, that it can be in- 
termitted and resumed according to the varying circumstances of each particular 
case." 

30. Oblique Fracture of the Femur immediately above the Condyles. — Mr. James 

Spence was sent for on the night of the 9th of July, 1845, to visit Mr. M , who 

had been found lying insensible at the foot of a very steep stair, down which it 
was supposed he had fallen. On arriving at his house, he was found lying on a 
couch ; the right thigh was fractured close above the knee-joint, and as the limb 
was imperfectly supported, the sharp point of the broken shaft of the femur was 
seen projecting, merely covered by the skin. There was great effusion around, 
and into the knee-joint, and the patella was found, after some manipulation, lying 
deeply seated towards the inner side of the projecting end of the shaft of the femur, 
and apparently locked between it and the condyles. By extension, the project- 
ing portion was considerably reduced, and then the appearance of the limb when 



1848.] 



Surgery. 



213 



viewed laterally was very similar to dislocation of the tibia backwards. On fur- 
ther examination, there was found a fracture of the neck of the humerus, and of 
the ribs on the same side, and several contused wounds of the head and. face. 
After putting up the fracture of ihe humerus and bandaging the chest, the patient 
was placed in bed, and it was attempted to complete the reduction and co-apta- 
tion of the fractured femur. Extension was made on the leg by two gentlemen, 
whilst counter-extension was kept up by means of a folded shawl applied as a 
perineal band by another party: but this attempt was ineffectual, as the projecting 
shaft seemed locked by the position of the patella. As the projection was to the 
outer side of that bone, extension was next made in an oblique direction in the 
axis of the broken shaft of the femur, and it was endeavored to disengage the bone 
from the muscles through which it had protruded, by bending the leg and thigh 
towards the pelvis: but these attempts were attended with but little further benefit 
to the position of the bone. The long splint was therefore applied to keep up 
what advantage had been gained by extension, and a large opiate, w'ith occasional 
doses of camphor mixture, was ordered. 

Next day, with Mr. Syme in consultation, further reduction was again attempted 
by extension, but ineffectually: the splint was therefore again applied. The pa- 
tient, who had been very excitable before the accident, became gradually worse: 
delirium set in, antimonials combined with opiates were given, but could not be 
continued, owing to the state of the pulse: the camphor mixture and opiates some- 
what relieved him and procured rest; but he gradually became worse and died on 
the 13th of July, the fourth day after the injury. 

With some difficulty permission was obtained to examine the broken thigh and 
take a cast of it; but no further examination was permitted. On dissecting off the 
skin, the sharp point of the broken shaft of the femur was seen to have perforated 
the crurseus and vastus externus muscles, appearing immediately on the outer 
edge of the tendon of the rectus, which it had also perforated; it overlapped and 
pressed firmly upon the upper and outer edge of the patella, locking it against the 
condyles of the femur. The condyles and the lower fragment of the femur, together 
with the leg, were drawn backwards, upwards, and rather inwards ; the sartorius 
and inner-hamstring muscles were very much relaxed. After taking the cast of 
the dissected limb, efforts were made to reduce the bone, but still in vain ; the 
wound was then enlarged upwards in the' axis of the bone, but without success, 
until the vastus was divided, together with a small part of the tendon of the rectus, 
in a transverse direction, when reduction was accomplished with the greatest ease. 
On this being done, the condyles separated, showing that they had been split up 
by the injury; and, on carrying the dissection further, the bone was found com- 
minuted into numerous fragments. 

Remarks. — The kind of fracture of which an example has been given is not of 
very frequent occurrence, and opportunities of examining the exact state of parts 
by dissection are very rare. Sir Astley Cooper, in his work on fractures, has given 
the history of two cases, and states, that he considers it 11 a most formidable injury 
from its consequence on the future form and use of the limb ; for it is liable to ter- 
minate most unfortunately by producing deformity, and by preventing the flexion 
of the knee-joint." He also gives an account of the dissection of a case of this 
kind of fracture which he had an opportunity of seeing in a body brought into 
the dissecting-room, and of which a plate is given in the large edition of his work. 
All the cases mentioned by Sir Astley, seem to have terminated unfavourably as 
regards the usefulness of the limb; and though he does not mention that there 
was any difficulty in reducing and replacing the bones, and seems rather to im- 
pute the bad result to the difficulty of keeping up extension, Mr. Spence was of 
opinion that the ordinary long splint would keep up the extension sufficiently, if 
the broken ends of the bone were fairly brought in apposition. From the state of 
parts found on dissection in the case related, as well as in the dissection given in 
Sir Astley's work, there must, in most of these cases, be great difficulty in freeing 
the end of the shaft from the muscular fibres through which it has protruded. 
Although the projection maybe considerably diminished by extension, there will, 
in cases where the bone has passsd through the crurseus and vastus muscles, be a 
risk of muscular fibres intervening between the broken surfaces, and so present- 
ing firm union. The position of the patella, also, firmly fixed to the inner side of 



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[July 



the projecting end of the shaft, and locked between it and the condyloid portion 
of the femur, serves to check extension and prevent the lower broken portion 
being brought into a line with the shaft. From the ease with which the bone was 
reduced after death, when the fibres of the muscles surrounding it were divided 
transversely, although it had previously resisted strong efforts at extension, and 
free longitudinal incision, the author, in similar circumstances, taking into account 
the usual unfortunate termination of such cases, considered himself warranted in 
dividing freely the muscular tissues surrounding the projecting bone by means of 
subcutaneous incisions, as any additional risk from such a proceeding would be 
more than compensated for by the advantage obtained from its facilitating the re- 
duction and co-aptation of the broken bone. It will be noticed that in this case, 
when extension was effected, the condyloid portion of the femur was found split 
longitudinally. This must be of very frequent occurrence in such accidents when 
the bone is broken so low down as in the case just related, and when we consider 
the anatomical formation of the femur near the knee-joint. But it is a lesion 
"which cannot be fairly ascertained so long as the other fracture is non-reduced, 
because the lower broken portion of the shaft presses the outer condyle against 
the inner, and so keeps them firmly locked together. — Proceedings of Medico-Chi- 
rurgical Society of Edinburgh, April 19th, in Monthly Journal and Retros. of Medical 
Sciences, May 1848. 

31. Case of Compound Fracture of the External Condyle of the Femur, laying open 
the Knee-joint, complicated with a simple Transverse Fracture of the Lower Third of the 
same Bone. By W. P. Brookes. — The subject of this injury was a lad, aged eleven 
years and a half. The accident occurred in 1845 : whilst the boy was in the act 
of getting up behind a coach, he fell, and the left leg and thigh got entangled be- 
tween the spokes of the hind-wheel whilst in motion. On examining the limb, 
the author found a compound fracture of the femur, extending obliquely down- 
wards through the external condyle, which was movable with the lower portion, 
projecting through a wound in the popliteal space. The leg was twisted inwards, 
much hemorrhage had taken place, and the patient was in a state of collapse. On 
farther examination, the capsular ligament was found to be lacerated, and synovia 
escaped, — the wound in the popliteal space being as large as a five-shilling piece. 
There was also a simple fracture of the lower- third of the same thigh-bone. 
When the boy rallied, amputation was proposed and urged as the only chance of 
saving life ; but the father refused to sanction the operation. The limb was there- 
fore adjusted, and the natural position maintained, as well as the circumstances 
would admit of, by a straight splint, extending from the hip to the ankle, and a 
concave one on the inner side of the thigh. For some time the constitutional dis- 
turbance was very considerable, but gradually subsided. At the end of the sixth 
week the splints were removed, and the fractures were found to be firmly united. 
The lad has recovered the entire use of the limb, on which he can bear his whole 
weight, and can bend the knee-joint at right angles. There is no perceptible dif- 
ference in length between the two limbs. Tne author concluded with some re- 
marks upon the rarity of recovery after so severe an injury, and considered that 
the case he had narrated should act as a practical lesson to the surgeon to trust 
more to the vis medicatrix naturce. — Proceedings of Royal Med. and Chirurg. Society, 
in Lond. Med. Gaz., March 1848. 

32. Fracture of the Olecranon — -new method of bringing the fragments into apposition. 
By M. Hervez de Chegoin. The difficulty of maintaining the two portions of a 
fractured olecranon in contact, without keeping the forearm in a position which, if 
fixedly preserved, would render its functions useless after the time necessary for 
consolidation had elapsed, has caused the greater number of surgeons to be satis- 
fied with a union as little mediate as possible, by preferring the semiflexed position 
of the limb to its complete extension, which, however, has been adopted by some 
with success. The case observed by M. Baudens is well known; and perhaps 
after a greater number of instances, this method will be more generally tried ; per- 
haps, too, it is more easy to betid an arm which has been kept long extended than 
to extend one which has been long flexed, because the muscles of flexion are 
more powerful than their antagonists. But the utility of a bent forearm, and the 



1848.] 



Surgery, 



215 



helplessness of an extended one, have till now given the preference to the semi- 
flexed position. In the meantime, I wish to make known a plan that I have 
recently adopted with the greatest success. 

A woman, 65 years of age, of very spare habit, fell violently on the staircase, 
and fractured the left olecranon a little below its middle. I did not see her till the 
next day; there was then considerable swelling above and within the articulation, 
down to the middle of the forearm ; while the point corresponding to the fracture 
was scarcely swollen, and the skin then preserved its natural colour, which gave 
reason to suppose that the fracture, though caused by the fall, was the result not 
of direct violence, but of muscular action. 

The fragments were separated by an interval of nearly half an inch; they were 
easily brought together by extension of the forearm and pressure on the upper por- 
tion, but an involuntary movement of flexion immediately separated them. 

The contusion of the arm and forearm had been violent. The swelling and 
ecchymosis increased on the following days, and extended to the hand. The pain 
became more severe on the eighth day, and the cold lotions were exchanged for 
emollient poultices. The joint, however, remained free from this tumefaction, 
which confirmed my view of the manner in which the fracture had been produced, 
and allowed me to see what took place between the two fragments. 

On the eighth day the interval between them was filled by a soft substance, 
which increased in quantity on the succeeding days, so as to rise above their level 
behind. It had become more liquid, and afforded an evident sense of fluctuation. 

On the fifteenth day it was much reduced, and allowed the finger to be placed 
between the fragments. By this time the pain and swelling of the forearm had 
nearly disappeared, but the ecchymosis remained down to the wrist, with a degree 
of induration of the soft parts. The forearm till now had been kept on a pillow in 
the semiflexed position without any apparatus, of which the patient was singularly 
apprehensive from the recollection of what she had suffered from bandages too 
tightly applied for a fracture of the clavicle. 

The object was now to bring the fragments together without exercising any com- 
pression, and at the same time to keep the forearm semiflexed. For this purpose 
I contrived the following apparatus: — I placed the limb in a hollow, jointed splint, 
deeply excavated behind so as to leave the posterior surface of the joint free. At 
the upper part of this hollow I fixed a piece of elastic gum, about two inches 
square and a third of an inch thick, by means of narrow tapes passed from within 
outwards through two holes made on each side. At the two inferior angles were 
fixed two other tapes, which I also passed from within outwards through two holes 
bored on each side of the lower margin of the excavated portion of the splint. I 
then applied the piece of elastic gum above the upper fragment, and by gently 
drawing the lower tapes, brought it easily into contact with the inferior fragment. 
Fearing, however, that this pressure might cause some pain, I loosened the tapes 
a little, satisfied that a slight but continued action would overcome the muscular 
resistance. 

The fragments became gradually approximated, merely taking care to tighten 
the tapes according as they became relaxed, and at the end of six weeks were so 
close that the finger could scarcely detect the interval between them. About the 
thirtieth day I began to give a little passive motion to the joint; this caused a little 
pain, not in the joint, which all along was free from any inflammatory action, but 
in the soft parts of the forearm, which for a long time continued indurated by the 
blood infiltrated in their substance and beneath the integuments, which, after two 
months and a half had elapsed, retained the yellow hue of old contusions. The 
patient, however, could execute with facility the fullest movements of flexion and 
extension. — Dub. Med. Press, May 24, from Gazette des Hopitaux. 

33. Cases of Ununited Fracture successfully treated. By W. B. Page, Esq. — The 
first case narrated by the author was that of a young man, whose radius and ulna 
had been fractured thirty-four weeks, before the operation of excising the fractured 
extremities of the bones was had recourse to. He had suffered from other frac- 
tures at the same time, which had united soundly. The injured forearm was an 
inch and a half shorter than the sound one ; the fracture of the bones was oblique, 
and the shortening resulted from overlapping of the extremities. The seat of 



216 



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[July 



fracture was exposed by incisions over either bone on the posterior aspect of the 
forearm ; and a curved director being passed beneath each fragment in succession, 
they were removed by means of a small Hey's saw, and with the assistance of 
cutting forceps. The forearm was then immovably fixed in an angular splint, in 
a position between pronation and supination. At the end of ten weeks, union 
was complete ; and after the lapse of six months, the patient had almost entirely 
recovered the original use and strength of his arm. The second case was one of 
ununited fracture of the tibia and fibula. In this instance the cause of non-union 
appeared to have been the want of entire and sufficiently prolonged rest, which 
was accordingly resorted to for two months, but without a satisfactory result. The 
author then inserted two setons, one over the outer, the other over the inner, sur- 
face of the fractured bone; but the threads were removed in ten days, in conse- 
quence of the inflammation that ensued. In two months more, union was com- 
plete. In the third case the injury was likewise a fracture of both bones of the 
leg. Mal-treatment caused protrusion of the tibia, a portion of which was removed 
with a saw at the end of two months ; and this operation was followed by repeated 
exfoliation from both tibia and fibula. In this way nine months elapsed before 
there was any attempt at union, when the patient came under the author's notice. 
His first care was to heal the wounds, and then to keep the limb at perfect rest 
for three months. Union was then complete. The fourth case was an illustration 
of non-union from want of proper nutriment. When this necessary adjunct to 
surgical assistance was supplied, the patient, a female, speedily recovered. In 
the fifth and last case, non-union of fractured tibia and fibula was accounted for 
by syphilitic taint in the system, which was corrected by the specific influence of 
mercury, and then union took place. The author concluded with some general 
remarks on the cause of non-union of fractured bones, as illustrated in the preced- 
ing cases, and by remarking that the serious operation of lesection of the frac- 
tured ends is admissible only in a limited class of cases, such as that narrated in 
his paper. — Proceedings of R. Med. C. Soc, in Lond. Med. Gaz. } March 1848. 

34. Diagnosis of Incomplete Fractures. — M. Debron, relating a case of fissured 
fracture of the lower end of the femur, which was undetected during life, observes 
that while the obscurity of these cases, owing to the absence of crepitus and all the 
usual symptoms, renders detection difficult, it is very important for the patient 
that this should be effected; else he is not placed under restrictions in the move- 
ments of his limb, which are essential to his well-doing, inasmuch as incaution in 
this respect has led to the development of inflammation, which has terminated in 
death, or the loss of the limb. Severe pain at the seat of fracture, distinguishable 
from the more diffused, less fixed, and less intense pain of the accompanying 
contusion, is one of the best signs. If the indication furnished by this is over- 
looked or inappreciable, and the limb is not secured, another sign manifests itself, 
viz., erysipelas arising at the very seat of fracture, thus developing itself after the in- 
flammation depending on the contusion had subsided. This erysipelas is accom- 
panied, too, by an cedematons or pasty feeling of the part. The delay (perhaps 
several days) in the appearance of this form of erysipelas, arises from the inflam- 
mation first occurring among the soft parts around the bone, and spreading from 
within outwards (inversely to what it usually does), it being, in fact, but a symp- 
tom of the suppuration which is going on between the bone and the muscles. — 
B. and F. Med. Ckir. Rev , April 1848, from Archives Gen., torn. xvi. 

35. On Petit's Operation for the Relief of Strangulated Hernia. By James Luke, 
Esq. — The object of the author in this communication was to place before the pro- 
fession the result of his experience in operating for strangulated hernia, without 
opening the sac. He remarked, that though experience was the only fair test by 
which the relative merits of this and the ordinary operation could be decided, the 
subject was encompassed by many obstacles, such as the impossibility of obtaining 
exactly parallel cases, the importance of not mixing the observations of different 
surgeons or judging from selected cases. To obviate these difficulties and sources 
of fallacy, the author has yielded up the whole of his experience on the subject of 
Petit's operation, which is the only mode of operating he has adopted since the 
year 1841, as an ordinary practice. Being unable to supply from his own case- 



1848.] 



Surgery. 



217 



book the result of cases operated upon by opening the sac, the author appealed to 
the experience of others, referring especially to statistical details given by M.Tex- 
tor, Mr. South, M. Malgaigne, and collected at the London Hospital, and from the 
British journals generally, which gave a return of mortality of from one-third to 
more than one-half. Where the taxis is successful, similar statistics prove that a 
fatal result is very rare. The conclusion which seems naturally to flow from these 
facts is, that operative interference should be deferred, and the taxis pursued as 
long as it offers any prospect of a successful issue — an inference, however, which 
the author considers to be fallacious and mischievous in its tendency, as involving 
a rife source of procrastination, which in itself is the too frequent cause of non- 
success attending the operation. This assertion is borne out by statistical details 
of cases operated on at different periods, after the establishment of symptoms of 
strangulation. The author then proceeded to remark that the desideratum ap- 
peared to be, the introduction of an operation by which the taxis would be aided, 
but without incurring the risk attending the ordinary operation, by exposure of the 
contents of the hernial sac; and these objects he considered to be fulfilled by 
Petit's operation. Inclusive of selected cases occurring between 1831 and 1841 7 
the author stated that he had attempted the performance of Petit's operation in 
eighty-two instances, which, with four exceptions, likewise comprised all the 
cases that had come under his care since 1841. Of this number the operation was 
completed, without opening the sac, in fifty-seven. In twenty-five it was neces- 
sary to open the sac to complete a reduction of the hernial contents — the opening 
varying in extent from half an inch to one inch and a quarter. With respecl to 
the mortality amongst these patients, — of the fifty-seven in whom the sac remained 
unopened, seven died; of the twenty-five in whom the sac was opened, eight 
died. The author considered, however, that for statistical purposes it was prefer- 
able to exclude the selected cases (twenty-six in number), together with four 
other cases, of which three were considered moribund at the time the operation 
was performed, and the fourth died of secondary stricture six weeks afterwards. 
Of the remaining fifty-two cases, the sac was opened in twenty one, of which 
three died, and not opened in thirty one, of which two died. Of the cases in 
which the sac was opened, in ten the strangulation of the contents had existed, 
before the operation was performed, under twenty-four hours, of which number 
one died; in eight, above forty-eight hours, of which one died. Of the unopened 
cases, the strangulation had existed in thirteen under twenty-four hours, of which 
not one died; in eleven, under forty-six hours, of which one died. The author 
considered it important that the small size of the opening made into the sac, in 
the former class of cases, should be borne in mind, as it doubtless had an important 
influence in diminishing the ratio of mortality attached to this mode of operating. 
He then passed on to further details relating; to the above cases, and the reasons 
for opening the sac, and stated that, of the fifty-two instances cited, twenty-nine 
were femoral, twenty inguinal, and three were umbilical hernia. He further 
pointed out the conclusion, from an analysis of the foregoing cases, that Petit's 
operation has proved most successful in the femoral form of hernia. In cases of 
inguinal hernia, the author limits his incision to a longitudinal division of the skin 
and fascia over the neck of the sac, of which cut the seat of stricture should be the 
centre. He then partially incises or scarifies the neck of the sac (if the seat of 
stricture, as it usually is), so as only partially to divide it, and so that it shall yield 
to the subsequent application of the taxis. In femoral hernia he considers it very 
desirable to avoid, as much as possible, interfering with the tumour in conducting 
the operation, and therefore recommends that a similar proceeding should be 
adopted — the centre of the perpendicular incision in this case being between the 
upper part of the tumour and the abdominal surface. Poupart's ligament is thus 
reached by carrying the finger from above downwards, and the stricture is divided 
on a director, introduced into the femoral ring. The operation advocated by the 
author is not considered by him to be so applicable in umbilical hernia, except 
where it is of small dimensions. The author concluded by noticing and combat- 
ing the various objections which have been raised to Petit's operation, and by 
insisting on its value, apart from other considerations, as holding out inducement 
to surgeons to proceed with less delay to the performance of the operation, as he 
considered that procrastination, arising from the dread of having recourse to the 



218 



Progress of the Medical Sciences. 



more severe operative interference ordinarily adopted, was in itself (as already 
remarked) a rife cause of the mortality which unhappily has too generally attended 
these cases. 

Of the patients who had died after the operation detailed, Mr. Luke stated that 
in the first case the patient died from exhaustion, four days after the operation. 
No symptoms of inflammation were present. The second case was one of umbi- 
lical hernia, in which the symptoms of strangulation did not subside, although 
there were unequivocal proofs that it was removed, as the bowels acted freely. 
In three cases the patients sunk so soon after the operation, that he could not say 
of what they died. The condition of the bowels was not examined into. In no 
case was there any sign of inflammation, either as the result of the operaiion, or 
of strangulation. — Proceedings of the Roy. Med. Chirurg. Soc, Feb. 22, from London 
Med. Gaz., March 1848. 

36. Operation for Strangulated Umbilical Hernia. By G. B. Childs, Esq. — At the 
meeting of the Royal Medical Chirurgical Society (Feb. 23). a plan proposed by 
Mr. Gay was mentioned, in which the object of the operator is to get at the stric- 
ture without at all exposing the hernial tumour. Mr. Childs has since performed 
in the operation in accordance to this plan. 

The hernial tumour, which was of two years' standing, had become strangulated 
on the evening of the 7th of March. It was at least eight inches in its longest 
diameter; lay principally to the left of the umbilicus, on the abdominal parietes, 
which it depressed to a depth that made the distance between them and the inte- 
guments very considerable; and obviously consisted of a large mass of omentum 
as well as intestine. An operation for its relief was immediately required, and 
that proposed by Mr. Gay adopted, on the grounds that, from its great size, the 
corpulency of the patient, and the extent of wound necessary for its performance 
in the ordinary way, hardly any but a fatal result could be anticipated from it. 

The patient was first placed under the influence of chloroform, and then a wound 
through the integuments and superficial fascia, not more than an inch in length, 
was made on the right side, just beyond the edge of the hernial mass. The finger 
was directed through the wound, and after separating some few bands of cellular 
and other tissues, which feebly obstructed its course, the neck of the sac was 
reached at a depth of at least four inches. The umbilical ring forming the stric- 
ture, was then felt constricting the neck of the sac, to which it was adherent, by 
means of some strong bands. These were broken down with the finger, but not 
without some difficulty, owing to the great quantity of fat, and consequent depth of 
the wound. A director was then insinuated between the sac and the ring, guided 
by the finger, which still remained in the wound, and the stricture divided. After 
breaking down some further adhesions, the parts were liberated, and the contents 
of the sac immediately returned. The patient had her usual truss applied at once, 
and no bad symptoms occurred to prevent her complete recovery. 

The usual fatality attending operations for umbilical hernia, would, in the prog- 
nosis of the present case, have excited grave doubts as to the result, had the old 
operation been adopted : and Mr. C. thinks that the simplicity of the principle 
upon which the new operation is based, the little difficulty in ordinary cases of 
practising it, and the lessened probability of its being followed by any severe 
symptoms, form very decided arguments in its favour. — Lancet, March 18, 1848. 

37. On the operation of Gastrotomy as applicable to cases of obstructed (Esophagus. 
By Prof. Sedillot. — The operation here proposed, consists in incising the abdo- 
minal parietes opposite the anterior wall of the stomach, making an opening into 
the latter, and connecting the edges of this opening with the external wound, so 
as to form an artificial fistula, by which sustenance may be administered in cases 
where irremediable obstruction of the natural passage exists. Such cases, if left 
alone, are quite desperate, their only possible termination being death by famine; 
and Sedillot, therefore, holds that it is justifiable to interfere by any means which 
offers a chance of safety. That the operation which he proposes is not impractica- 
ble, is proved by various cases (such as that of the celebrated Alexis St. Martin), 
in which a stomachal fistula occurred, as a consequence of accidental wounds ; and 
also by the experiments of Blondlot on animals, in one of which he kept a dog in 



1848.] 



Surgery. 



219 



health two years, nourishing him by means of an artificial fistula of the kind de- 
scribed. Experiments of this description have also been performed by Sedillot 
himself, with a successful result. With these facts before him, he argues, that, 
although gastrotomy ought not to be proposed where there is a probability of life 
being continued for some time without interference, yet in those in which death 
is evidently imminent, and where there is no other resource, the surgeon ought not 
to hesitate about giving his patient the chance of a prolonged existence, and free- 
dom from suffering. 

If this be admitted, it is evidently of great importance to keep in view those 
circumstances under which obstruction of the oesophagus might render such an 
operation necessary. The author, therefore, enters into an elaborate review of all 
those lesions of the oesophagus which lead to permanent constriction of the natural 
passage. He gathers from pathological writers a great variety of cases, which he 
arranges under fifteen heads, viz : — 

1. Congenital absence of part of the oesophagus. 

2. Stricture in consequence of tumours in the neighbourhood of the oesophagus. 

3. Tumours formed between the tunics. 

4. Hernia of the mucous membrane. 

5. Polypi. 

6. Stricture, by atrophy of the tube, without appreciable lesion of its walls. 

7. Atresia, from cicatrices, with loss of substance. 

8. Fibrous stricture. 

9. Fibrous degeneration of the muscular coat. 

10. Cartilaginous stricture. » 

11. Osseous transformation. 

12. Complete obliteration. 

13. Cancerous stricture. 

14. Impermeable stricture of the cardia. 

15. Fatal oesophageal stricture without known cause. 

The cases to which the operation is applicable, as above enumerated, appear to 
be referable to two divisions; the first being those cases in which the operation is 
performed without hope of modifying thereby the original diseased condition, and 
merely to prevent death by hunger; the second, comprising cases in which the 
original condition is susceptible of modification, and where the establishment of 
a new passage to the stomach either assists the cure, or prevents the further pro- 
gress of the disease. In this respect, the proposed operation has a close analogy 
in its mode of application to the more familiar one of tracheotomy. 

The principal cases to which gastrotomy is applicable, according to Sedillot, 
wilh the double purpose above mentioned, are those comprised in the 4th, 7th, 
and 13th sections of his arrangement. In the 4th series, in which the mucous 
membrane is thrust through the other tunics, so as to form diverticula, he holds 
that the constant passage of the food distending these abnormal pouches is certain 
to keep up the morbid lesion, and, even by dilating the pouches still farther,, to 
hasten the ultimate obliteration of the normal passage; whereas, if the operation 
of gastrotomy be performed, there is a probability that the pouch may, in time, 
contract and obliterate itself. In the 7th series, comprising all the wounds and 
inflammatory lesions of the oesophagus, in which there is hope that the judicious 
employment of catheterism might ultimately restore the tube to its function. Sedil- 
lot holds that gastrotomy will often permit us to continue this treatment when 
otherwise the death of the patient by inanition would have frustrated our efforts; 
and he believes that, in such cases, the chances of cure will often be greatly in- 
creased by the complete rest which is obtained in the intervals of treatment for the 
diseased portion. Finally, in the truly cancerous lesions, where the diagnosis can 
be ascertained with any degree of certainty, he conceives repose of the part to be 
of the first consequence, as both catheterism and the passage of food through the 
cancerous part, tend very much to the rapid progress and fatal issue of the disease ; 
and he thinks, therefore, that gastrotomy may possibly be found to be applicable 
to cancerous cases at an earlier period than that at which death by inanition is im- 
minent. 

It is necessary to state, that tha operation has never yet been performed by Se- 



220 



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[July 



dillot, although he so strongly advocates its performance — Med. Journ. and Retrosp. 
of Med. Sci., April 1848, from Gazette Medicate de Paris, Jan. 1847. 

38. On the Treatment of Strictures of the (Esophagus by Catheterism and Cauteriza- 
tion. — M. Gendron is of opinion that many strictures of the cesophagus, which at 
first appear incurable, will be found to yield to careful and protracted treatment 
by the cesophagus-bougie, with occasional use of cauterization. He objects to the 
treatment proposed by Sedillot (see last article) as being unpractical and hazard- 
ous. The use of the bougie, on the contrary, is in no way dangerous if due care 
be taken; and the objections of the patient to it are of short duration, as the oeso- 
phagus becomes very soon accustomed to the stimulus of the instrument. So 
long as there is any obstruction, it is necessary to support and guide the bougie in 
its passage downwards, by means of two fingers of the left hand introduced into 
the pharynx. Dilatation occurs very gradually, and sometimes there appears to 
be a re-contraction, readering it necessary to return to a smaller size of instrument 
after some progress has beeh made. The completeness of the cure is to be judged 
of chiefly according to two circumstances: — First, the ease with which a full- 
sized bougie can be passed, using one hand only ; second, the disappearance of the 
tracheal rale, and unnatural quality of the voice, which almost invariably accom- 
pany an oesophageal stricture. 

M. Gendron alludes to four cases in which he has succeeded in curing tight 
strictures of the oesophagus by the method here spoken of. Three of these were 
in consequence of diphtherite; one was without known exciting cause; one was 
not more than eighteen days under treatment; the rest from one to two months. 
Cauterization, by nitrate of silver, w T as employed in three of the cases; in two 
repeatedly; in the other, only twice. The elastic bougie, or the whale-bone staff 
with sponge, was used at short intervals ; often several times in each day, but not 
so frequently after cauterization. — Ibid., from Ibid., No. 11. 

39. Fractured Patella — Subsequent Laceration of the Soft. Parts, implicating the Joint. 
— Dr. Croker King related the following example of this very rare accident, to 
the Surgical Society of Ireland (Nov. 20th, 1848). 

The subject of it, a gentleman, was tripped by the rope of a canal boat, and, in- 
effectually endeavoring to regain his feet, he fell to the ground, from which he 
was unable to rise without assistance; this occurred on the 29th of Sept., 1846. 

On examination a fortnight after the receipt of the injury, a transverse fracture 
of the right patella above its centre was apparent : the fragments were separated 
about three-fourths of an inch. The injury was treated in the usual manner; co- 
aptation of the fragments was accurately maintained, but bony union did not take 
place. 

On the 2d of March, 1847, five months from the receipt of the accident, the 
limb presented the following appearance : — The fragments had become separated 
to the extent of half an inch. The motions of the knee-joint were still consider- 
ably restricted, though it could be slightly bent. The patient could walk tolerably 
well without the assistance even of a stick. The joint measured thirteen inches 
and a half in circumference, the tape being carried round the joint at the seat of 
fracture. 

On the following morning I received a hurried summons to visit this gentleman, 
who resided some distance from town. On my arrival [ was informed that on the 
previous evening (while crossing the room), the knee had suddenly bent under 
him, that he suffered a severe shock, was sensible of something having given way, 
and that the knee Jiad burst, and bled profusely. 

On examination, an immense gash presented itself; it ran across the front of 
the joint corresponding to the interval between the fragments, which were now 
separated at least one inch and a quarter. The wound was half an inch wide and 
seven inches long, and consequently exceeded in extent half the circumference 
of the limb. The w^ound was occupied by coagula of blood, which had become 
hard and dry, fourteen hours having elapsed from the receipt of the injury. 

I certainly felt much alarm for the safety of the limb on inspecting this formida- 
ble wound, as I did not see how the joint could have escaped being laid open. It 
was evidently the most judicious plan not in any way to disturb the dried coagula. 



1848.] 



Surgery. 



221 



An attempt was made to approximate the edges of the wound. Such was found 
impracticable, as the skin was adherent to the separated fragments of the patella. 
The limb was placed on a hollow splint, and the integuments supported by broad 
strips of adhesive plaster to pre vent the further retraction of the edges of the wound, 
and the entire was covered with light dressing. 

In a few days severe constitutional disturbance supervened; the tongue furred ; 
the pulse beat hard and frequent ; and suppuration was freely established. On 
pressing the lower fragment, it yielded, and a copious discharge of purulent matter 
issued from the centre of the wound, and from the angles a transparent fluid, 
presenting all the appearances of synovia : the fever quickly assumed a hectic 
character 

A deep-seated abscess now formed on the inside of the limb, extending upwards 
for at least eight inches. The patient's countenance was expressive of much dis- 
tress. The nights were passed with little sleep; and notwithstanding the exhibi- 
tion of three grains of solid opium on the previous evening, the patient had en- 
joyed little rest, being constantly disturbed by pain and severe spasms extending 
up the limb; the pulse had risen to 120; the tongue was heavily coated, and the 
patient rapidly emaciating; there was, in addition, diarrhoea with bloody discharges, 
cutting pains in the abdomen, and night perspirations — in fact, the case was alto- 
gether as unpromising as it well could be, and the question of amputation as the 
only probable means of saving the patient's life of course suggested itself: how- 
ever the liberation of the contents of this extensive abscess was first determined 
on. I made an incision an inch and a half long, four inches above the joint, and 
gave exit to ten ounces of most abominably fetid pus, mixed with clots of blood 
and sulphuretted hydrogen gas, which bubbled up through the matter — in fact, just 
such a discharge as we see in a suppurating hematocele. On the following day 
the matter having gravitated in considerable quantity and accumulated in the vi- 
cinity of the knee, I passed a director through the wound downwards to the most 
depending position, and, cutting on its extremity, thus made a counter opening. 
This great sinus being thus completely emptied, its walls were carefully and in 
the most accurate manner approximated by means of a circular bandage and well- 
adjusted compresses. 

On visiting the patient on the following day, the change which had taken place 
in his general appearance was not a little remarkable. The haggard and fretted 
look had been replaced by a joyous expression. On inquiring how he felt, he 
replied " gaily;" he had, in fact, slept soundly; experienced no pain; the pulse 
had fallen to 80 ; the diarrhoea and night perspirations had ceased, and never re- 
turned; and what certainly surprised me, the walls of the sinus had become ad- 
herent at every point; there was not a single drop of discharge from the incisions, 
nor was there the slightest tension. 

From this time the case progressed most favourably ; the amount of discharge 
from the wound, which was a little tedious in healing, daily diminished, and 
cicatrization was complete on the 4th of April, thirty-three days from the receipt 
of the injury. 

The cast which I exhibit was taken seven months subsequently. You observe 
a great transverse cicatrix corresponding to the wound, and two smaller perpen- 
dicular ones marking the site of the incisions. The fragments are at present two 
inches apart, and in the interval the external condyle of the femur is to be plainly 
seen and felt, apparently having no other covering but the integuments, and you 
may perceive that the transverse cicatrix runs immediately above the lower frag- 
ment. 

The separation and the apparent total absence of lioamentous union between 
the fragments imperatively demanded some mechanical support to prevent a 
second yielding of the limb. I was enabled to obtain a very efficient apparatus 
from Mr. Millikin of Grafton-street. It consists of sole leather so prepared as to 
accurately mould itself on the irregularities of the joint. This gives complete 
support, and the gentleman is able to walk about without any other mechanical 
assistance. 

Bell, in his Operative Surgery, mentions having observed a similar case. " I 
have seen," he remarks, '•' a very terrible accident follow the imperfect cure of 
the fractured patella. The bone had united by ligament, and this ligament had 
No. XXXI.— July, 1848. 15 



222 



Progress of the Medical Sciences. 



[July 



incorporated with the skin in such a manner that it lost much of its pliancy. The 
poor man was carrying a burden and fell backward, the knee sunk under him, 
and the whole forepart of the joint was laid open by laceration. The case ter- 
minated in amputation of the limb." — Dublin Med. Press, Dec. 8th, 1848. 

40. Cathcterism . — The apertures in the catheter sometimes during its introduc- 
tion into the bladder become completely plugged with coagulated blood, entirely 
preventing the flow of urine through the instrument. The following suggestion for 
overcoming this difficulty, offered by Mr. W. N. Sprong, (Lancet, June 9th, 1848,) 
it seems to us will prove highly useful. He proposes to introduce the pipe of a 
common syringe into the orifice of the catheter, and by drawing up briskly the 
piston, the blood, he says, will be drawn into the cylinder of the catheter when the 
urine will flow quickly. 

41. Tracheotomy in Tetanus. — Dr. Hughes stated at a meeting of the South Lon- 
don Medical Society, Feb. 3d, that lately tracheotomy had been performed for the 
relief of tetanus, from the belief entertained by some, that death occurred in many 
cases from spasmodic closure of the glottis, but it had entirely failed; showing 
clearly that this accident was not always the cause of death. — Lond. Med. Gaz., 
Feb. 1848. 

42. Death from Air entering a Vein divided whilst inserting a Seton in the Neck. — 
An accident of this kind has recently occurred at Barnes, near London. No blame 
could be attached to the operator. 



OPHTHALMOLOGY. 

43. Painful Affection of the Eye cured by the Extraction of a Tooth. — Dr. Emmerich 
relates a case of this kind. A man consulted him on account of a painful affec- 
tion of one of his eyes, which had lasted for nearly fourteen years, and occasioned 
him great suffering. There was considerable vascularity of the conjunctiva and 
sclerotica, especially around the cornea, which structure itself Was somewhat 
opaque and spotted. There was a continued flow 7 of tears, with pain and intole- 
rance of light. All these symptoms were greatly aggravated by any indiscretion 
in diet, and the use of the slightest stimulus, such as a single glass of wine. All 
kinds of remedies had been in vain tried, at different times, and the affection 
seemed incurable. On examining the upper jaw, Dr Emmerich found a carious 
molar tooth on the side corresponding to that of the affected eye ; the portion of jaw 
around this tooth was painful, and very sensitive to the touch. The patient thought 
that the pain in his jaw had begun about the same time that the affection of the 
eye commenced. The tooth was drawn, and almost immediately afterwards the 
symptoms relating to the eye began to subside, and soon entirely disappeared. The 
suffering in the eye was evidently the result of sympathy between the second and 
third branches of the fifth pair of nerves. — Dub. Med. Press, April 19th, from Henle 
and Pfeuferh Zeitschrift, 1847. 

44. The Eye naturally adapted for Distant Vision. — Volkmann and Hueck both 
agree in considering that, in its quiescent state, the eye is adapted to the vision of 
objects situated at the furthest point of distinct sight, and not, as has been gene- 
rally supposed, of those situated about midway between this and the point of dis- 
tinct vision nearest to the eye. In this case, therefore, in order to accommodate 
itself to the vision of an object placed at any distance within the furthest point of 
sight, the eye will require but one act, that, namely, of increasing its focal distance 
in proportion to the nearness of the object under view: no act will be requisite to 
adapt it to the perception of distant objects, for, in reverting to its state of rest, it 
at once resumes its capacity for distant vision, and retains it so long as its quies- 
cent state continues. In proof of this opinion Volkmann observes that, in a state 
of rest, the axes of the eyes are directed towards a point even considerably beyond 
the most distant point of distinct vision, and that, since changes in the position of 



1848.] 



Midwifery. 



223 



the axes usually correspond with changes in the adaptation of the eyes, it is im- 
probable that the meeting of the axes beyond the most distant point of vision should 
coincide with an adaptation of the eyes for an object on this side the point. Ac- 
cording to Hueck, this view will also explain the distinct formation of the image 
of distant objects on the retina after death; as also the far-sightedness induced by 
the action of hyoscyamus and of belladonna. — Lond. Med. Gaz., May 1848 ; from 
Baly and Kirke's Recent Advances in Physiology. 



MIDWIFERY. 

45. Disorders of the Nervous System during Pregnancy. — Dr. Lever, in an interest- 
ing paper on this subject in the fifth volume of Guy's Hospital Reports, lays down 
the following propositions as the results of his observation : — 

1. That pregnancy is occasionally associated with chorea, or convulsive move- 
ments; with paralysis of various parts of the body, of the extremities, and of the 
nerves of special sense ; and with mania. 

2. That the varying symptoms of such complications may be produced at any 
period of pregnancy; but when produced, although modified by treatment, are 
rarely removed during the existence of gravidity. 

3. That the patients in whom these complications exist, are women of a highly 
nervous temperament, of great irritability, or whose constitutional powers have 
been reduced by some long-continued but serious cause of exhaustion. 

4. That in the treatment of such cases, heroic measures are not to be employed; 
that the curative means consist in improving the secretions, keeping the bowels 
free, and administering those medicines, and employing that diet, which will in- 
crease the tone and energy of the nervous system. 

Lastly, That although, in most instances, the symptoms will continue as long as 
pregnancy exists; yet in the majority of cases we are not justified in inducing a 
premature evacuation of the uterine contents. 

46. Inflammation and Abscesses of the Uterine Appendages, (Ovaries, Fallopian Tubes, 
and Cellular Tissue.') By Dr. Henry Bennett. — During the last thirty years, the 
subject of pelvic abscess, considered generally, has been much studied by French 
pathologists — by Meniere, Andral, Grisolle, Marchal (de Calvi,) &c. In our own 
country it has received comparatively little attention, if we except the valuable 
articles of Dr. Doherty and Dr. Churchill, in the Dublin Medical Journal, and the 
recent article of Dr. Lever, in " Guy 7 s Hospital Reports? 1 By all these authors 
this disease is considered as all but characteristic of the puerperal state, and as very 
seldom occurring under other circumstances. This, the universal view of the pro- 
fession with respect to the pathology of inflammation and abscess of the uterine 
appendages, the author considers is very far from being a true interpretation of the 
facts. In reality, the disease is not at all uncommon in the non-puerperal state, 
only it is not recognized, being confounded either with acute metritis, chronic 
metritis, iliac abscess, or some other pelvic lesion. The principal difference that 
exists between the puerperal and non-puerperal forms of inflammation is the fol- 
lowing: — In the former, owing, probably, to the increased quantity of fibrin con- 
tained in the blood, there is a great tendency to inflammation. Hence, if the 
structures contained in the lateral ligaments are attacked with inflammation, the 
tendency of the latter to invade the peritoneal folds themselves, and the surround- 
ing tissues, gives rise to the formation of large pelvic inflammatory tumours, ab- 
dominal adhesions, and perforations, often ending in death. In the non-puerperal 
state, on the contrary, inflammation of the uterine appendages seldom extends to 
the peritoneum, and. the purulent formations nearly always escape, in a latent 
manner, by the rectum or vagina. In this form of inflammation of the organs 
contained within the folds of the lateral ligaments, the element most frequently 
attacked is the cellular tissue which separates the peritoneal folds, and surrounds 
the ovaries, round ligaments, and Fallopian tubes. It may be produced by any 
cause which exaggerates the vitality of the uterine system. The author has seen 
it occur frequently from ulcerative diseases of the cervix, or from a severe fall. 



224 Progress of the Medical Sciences. 



[July 



The inflammatory tumefaction to which it gives rise may be attended with suf- 
ficient swelling to be recognized by pressure over the abdominal parietes; but an 
accurate diagnosis can only be formed by examination per vaginam. It may 
terminate by- resolution, but more generally by suppuration, and the discharge of 
pus by the rectum, vagina or bladder, or by perforation of the abdominal parietes. 
When this takes place, however, the disease is not brought to a close, but during 
a longer or shorter period the patient continues to discharge pus in a latent man- 
ner, and to suffer from the symptoms of chronic uterine or pelvic disease. After 
giving this description of the disease in question, the author briefly alludes to the 
treatment, which, he observes, must be merely that of phlegmonous inflammation, 
carried out in accordance with the laws of therapeutics. The length of the paper 
precluded him from illustrating his account by cases, although he had seen many 
of great interest. He detailed, however, the heads of one which he had attended 
during the last year. 

In the acute stage of inflammation of the lateral ligaments, the treatment ought 
to be the same as that adopted in phlegmonous inflammation generally. Only the 
necessity of resorting to active antiphlogistic measures — bleeding, leeches, cathar- 
tics, mercurials, &c. — was even more urgent than in the ordinary forms of phleg- 
monous disease, owingto the disastrous consequences that generally follow suppura- 
tion in this region. In acute metritis, also, the disease with which inflammation 
of the lateral ligaments in the non-puerperal form is the most frequently confounded, 
there is infinitely less tendency to suppuration, and it is not, consequently, of such 
paramount importance to overcome the inflammation within the first few days of 
its manifestation. Hence the great importance of an accurate diagnosis. When 
once we are acquainted with the real nature of the disease, we know what to ex- 
pect, and can act accordingly. What he relied on the most, however, was the 
repeated application of leeches, within short intervals, on the abdominal parietes, 
just over the seat of the inflammation. In the acute stages, unfortunately, leeches 
could not well be applied internally, owingto the extreme sensibility of the vagina, 
and uterine system generally, which precluded the use of instruments. In the 
chronic stage, however, it became possible to use specula, and thus apply them 
internally. When this could be done, their application was attended with the 
greatest benefit. In this period of the disease, vaginal injections were often of 
great use; it was necessary, also, to enforce complete rest, and such general treat- 
ment should be adopted as was most calculated to strengthen the patient, and to 
improve the state of the economy in general. — Proceedings of Royal Med. Cliirurg. 
Soc, Jan. 26, in Lond. Med. Gaz. } Feb. 1848. 

47. Post- Puerperal Metritis. By MM. Chomel and Willemin. — Under this term 
M. Chomel has been long in the habit of describing a form of metritis, which does 
not manifest itself shortly after labour, as is the case with ordinary metritis, but at 
a period varying from eight to thirty days; the principal cause of its production 
being the resumption of the occupations of life prematurely, before the uterus has 
regained its normal volume. This organ becomes, under the influence of the 
metritis, much re-enlarged, while the os uteri is sensitive to the touch, tumid, 
irregular, and often lacerated. The treatment consists in baths and cataplasms, 
and laxatives in slight cases, bleeding where the pain and general symptoms 
require it, and afterwards local resolvents or exutories for the lessening the en- 
larged uterus. 

Dr. Willemin has furnished a very good essay upon this subject. He prefers 
the term simple idiopathic puerperal metritis, inasmuch as it occasionally presents 
itself at a much earlier period than is understood by the term post-puerperal : but it 
is always quite distinct from that form of metritis connected with pyogenic disease. 
According to the analysis given of ten cases, it is shown that symptoms occurring 
in some of these may be wanting in others. Thus there are (1) cases in which 
pain, fever, and anormal volume are present. In others (2) there are pain and 
increased size, but no general reaction. 3. Neither pain nor fever is present, but 
there is anormal volume, with sanguinolent lochia, and, in some cases, deep lace- 
ration of the os uteri. 4. The rarest form occurs when there is absence of fever 
and enlargement, while -there are pain and sanguinolent lochia. Any of these 
forms may, and frequently do, become complicated with inflammation of the sur- 



1848.] 



Midwifery. 



225 



rounding cellular tissue of the pelvis, producing iliac phlegmon. The disease is 
generally, but not always, more acute in proportion as the time elapsed since the 
labour is short. The neck of the uterus is found to be changed in position, or not 
to have resumed its normal state ; but the author has not observed the sensitiveness 
described by others. He is disposed to attach much importance to the deep lacera- 
tion of this part observed in 4 out of 10 of his cases, and easily recognizable in one 
of them twenty days after labour. The sanguinolent character of the lochia is a 
symptom to be remarked, and when iliac phlegmon complicates the disease, it oc- 
curs usually on the right side only. Bleeding, linseed cataplasms, and emollient 
glysters relieve the acute symptoms; and local applications, with, above all things, 
rest, suffice for the subacute form. For the iliac phlegmon, M. Rayer employs 
with great advantage, first, a general bleeding and purgatives, and then a large 
flying blister. If fever persists, he repeats the bleeding, and covers the whole 
hypogastric region successively with blisters. — Br. and Fr. Med. Chir. Rev., April 
1848. from Arch. Generates, vols. xv. and xvi. 

48. Vomiting in Pregnancy. — M. Trousseau, in one of his recent clinical lectures, 
took the opportunity of stating the great advantage he had seen accrue from the 
mode of treating obstinate arid dangerous vomiting during pregnancy, adopted 
some years since by M. Bretonneau. It first occurred to that practitioner, owing 
to the fact of his patient suffering from violent uterine pain, for the relief of which, 
believing the vomiting to depend upon its presence, he ordered a belladonna lotion 
to be applied to the hypogastric region, and with the effect of removing both the 
pain and the vomiting. In subsequent cases the remedy proved as efficacious, 
although no pain was felt ; and he explained its operation upon the supposition 
that the vomiting was then sympathetic of irritation of certain of the nerves of the 
ganglionic system only, produced by the enlargement of the uterus. However 
this may be, many others have adopted the practice with like success. — Ibid.. 
from Gazette des Hopitaux, No. 1, 1848. 

49. Tntra-uterine Peritonitis in the Fcctus. — Dr. Simpson showed to the Edinburgh 
Obstetrical Society (Feb. 9th), the body of a new-born infant which had died 
a few days before birth of acute peritonitis, as evidenced by quantities of coagu- 
lable lymph effused upon various parts of the surface of the peritoneum, and 
more particularly on the surfaces of the spleen and liver. Dr. Simpson stated 
that, 1st. Acute and fatal peritonitis appeared to be a very common inflam- 
matory disease in the foetus in the latter months of utero-gestation. 2d. A large 
number of foetuses dying in the seventh and eighth month of utero-gestation, 
presented, as he had found on dissection, well-marked anatomical evidence of 
it, in the presence of effusions of coagulable lymph, adhesions between the folds 
of intestines, pus, &c. 3d. The child was sometimes, though rarely, born alive, 
and affected with it. 4th. Far more commonly the child is born dead, and the 
previous history of the mother shows that it had perished, from one to three 
weeks before its expulsion, its movements having ceased about that time. 5th. 
Before the child's movements entirely ceased, the mother very generally remarks 
that its movements are morbid and excessive for fifty or sixty hours previously — 
probably during the currency of the fatal disease. 6th. Peritonitis is occasionally 
apt to recur in successive children in the same mother, and seems in some a result 
and remnant of the syphilitic poison in the parents. 7th. But in most cases its oc- 
currence is independent of syphilis, and occasionally it will not attack successive 
children in the same mother, or even both children in cases of twins. In an essay 
on the disease, published some years ago in the Edinburgh Medical and Surgical 
Journal, vol. i. p. 392, Dr. Simpson had described a case of twins, in which one 
was born living and healthy; the other was dead, and within the abdomen were 
found all the usual appearances following intra-uterine peritonitis. Whilst intra- 
uterine peritonitis was very common, intra-uterine pleuritis was very rare; Dr. 
Simpson had only seen two well-marked cases of it in the foetus. — Monthly Journ. 
and Retrosp. Med. Sci., May 1848. 

50. Case of Double Cephalhematoma. — Prof. Simpson showed to the Edinburgh 
Obstetrical Society, a child two weeks old, with a well-marked, large, and defined 



226 



Progress of the Medical Sciences. 



[July 



cephalhsematomatous swelling on each parietal bone, with the hard rim well 
marked at different points. He had never seen it on both sides except in this 
case. In this, as in most other cases, the tumours had not been observed till the 
first washing of the child, having come on, or at least grown greatly for some 
hours after birth. The effused blood was already becoming absorbed, and, by 
leaving the case entirely to nature, a cure would soon be effected. The effusion 
was between the skull and pericranium. He had watched various cases during 
the process of a natural cure, and he several times found that a layer of bone is 
formed on the inner surface of the separated pericranium, which can sometimes 
be distinctly felt after a time to crackle under the finger like parchment, — and, as 
the fluid gets absorbed, the two plates of bone gradually approximate and come 
together. Dr. S. believed that such cases were often mistaken and mistreated, by 
too active measures being employed. He had now had an opportunity of seeing a 
number of cases of cephalhematoma, and had never seen any treatment required 
but time and patience. The difficulty in their management generally, consisted 
in keeping the friends and others from doing something or other to them, when 
nothing, in reality, was required. — Ibid., April 1848. 

51. Maternal and Infantile Mortality in the Dublin Lying-in Hospital. By Dr. 
Clay. — The Dublin Lying-in Hospital was founded by Dr. Moss in 1757; from that 
period down to 1847, it has been under the charge of fourteen different physicians, 
or masters, as they are termed, who generally have held this important and lucra- 
tive appointment for seven years each. The following table shows the number of 
women delivered during each mastership, and the proportion of mothers and of 
children lost under the charge of the different successive physicians of the hospital. 
The per-centages present, says Dr. Clay, " an almost undeviating uniformity," 
eighty or ninety years ago the mortality under the two first masters, Dr. Moss and 
Sir Fielding Ould, being nearly precisely the same as since 1833 under the two 
last masters, Dr. Kennedy and Dr. Johnson. 

Table of the Maternal and Infantile Mortality of the Dublin Lying-in Hospital, 
under different Masters. 



Name of Master. Number of Deliveries. 



Number of Mothers lost. Number of Children lost. 



Dr. Moss, . . 
Sir F. Ould, . 
Dr. Cullum, . 
Dr. Jebb, . . 
Dr. Rock, . . 
Dr. Clarke, . 
Dr. Evory, 
Dr. Kelly, . 
Dr. Hopkins, 
Dr. Labatt, . 
Dr. Pentland, 
Dr. Collins, . 
Dr. Kennedy, 
Dr. Johnson, . 



915 
3,800 
4,724 
5,903 
7,088 
10,787 
11.357 
14^790 
18,727 
21,867 
12,885 
16,391 
13,167 
13,699 



14; 

49; 

65; 

63; 

54; 
124; 

86; 
163; 
217; 
309: 
198; 
158; 
224; 
179: 



or 1 in 65 
or 1 in 77 
or 1 in 73 
or 1 in 93 
or 1 in 131 
or 1 in 87 
or 1 in 132 
or 1 in 90 
or 1 in 86 
or 1 in 70 
or 1 in 65 
or 1 in 103 
or 1 in 58 
or 1 in 76 



46; 

197; 

258; 

269; 

411; 

580; 

600: 

974 \ 
1063; 
1535; 

827; 
1017; 

651; 

863; 



or 1 in 20 
or 1 in 19 
or 1 in 18 
or 1 in 22 
or 1 in 17 
or 1 in 19 
or 1 in 19 
or 1 in 15 
or 1 in 17 
or 1 in 14 
or 1 in 15 
or 1 in 16 
or 1 in 20 
or 1 in 16 



Total, 



1903; or 1 in 8: 



9291 ; or 1 in 17 



The 156,100 women delivered in the hospital have given birth to 82.267 boys, 
and 76,169 girls, or the proportion of male to female births has been as 12 to 11; 
twins occurred 2400 times, or in the proportion of 1 in 65 of the deliveries; there 
were 32 triplet cases, and 1 case of quadruplets. 

In the Registrar-General's returns we have the proportion of maternal deaths 
in childbed in England and Wales published from 1839 to 1842. During these 
four years 2,024,774 women were delivered, and 11,598 of them died. Hence, 
the proportion of mothers dying in childbed during these years in England and 



1848.] 



Anaesthetic Agents, 



227 



Wales, was 1 in every 174 deliveries. It is, however, to be recollected, that al- 
ways and everywhere the results of private practice are more favourable than 
those of hospital practice. — Ibid., May 1848, from British Record of Obstetric Med., 
for April 1848. 



ANAESTHETIC AGENTS. 

52. Varieties of Anaesthesia, fyc. — M. Beau, Physician to the Hotel-Dieu, has been 
engaged lately in pursuing some investigations into the history of anaesthesia or 
loss of sensibility. The following abstract conveys some of the chief results arrived 
at by that physician. He first points out that anaesthesia itself has two forms ; one, 
where the feeling of contact, as well as that of pain, is wanting; the other, where 
the sensation of pain only is wanting, the contact of any body being felt. The 
first of these two varieties affects only portions of the body, and is very rare; the 
latter is much more frequent, less grave, and although it may pervade the entire 
surface, yet oftener is more marked in the extremities, and especially in the arm 
and forearm. The anaesthesia of pain, moreover, is sometimes not limited to the 
skin, but extends to the mucous membrane, particularly to such portions of it as 
are normally endowed with high sensibility, such as those covering the eye, the 
nose, pharynx, &c. 

Each of these varieties is met with in cases of poisoning from lead, and either 
in company or separately. When the two are conjoined, the case is more severe 
and of longer duration ; when there is only loss of pain, recovery will happen, 
under proper treatment, in six days; but when with this there is also anaesthesia of 
touch, it is not until twelve or fifteen days have elapsed that the patient regains 
his healthy condition. The return of sensibility is the more rapid the less the 
duration of the malady, and the younger the patient. Tn considering the return of 
sensation, it must be borne in mind that the patient, though insensible to pain arti- 
ficially produced, is highly sensitive to what, as opposed to that, may be called 
constitutional pain, such as colic and gouty pain. 

That anaesthesia exists in the Protean-like disorder, hysteria, is known by expe- 
rience to all practitioners. One patient will be sensible only to temperature, or 
appreciate the dryness or humidity of bodies; another will feel only their form, 
and be insensible to pain ; the latter is by no means uncommon. 

Hypochondriasis is another malady, in which, from the abnormal state of the 
nervous system, pain is unfelt, although the contact of bodies is perceived by the 
sentient surface. 

The anaesthesia in hysteria and hypochondriasis may be attributed to the simply 
disordered condition of the nervous centres, whilst that in lead poisoning is con- 
nected with the direct action of the noxious mineral upon the nerve matter. 

Examples of the loss of sensibility are further seen in delirium after accidents 
and operations, where the wounded parts seem to be moved about with impunity 
of suffering; also in certain forms of insanity; and lastly, in persons who have 
wrought their minds to a pitch of enthusiasm. But it is only in the three first- 
mentioned disorders that the occurrence of anaesthesia presents any constancy or 
regularity.— -Lancet, May 20, 1848. 

53. Physiological Action of Chloroform.—- M. Amussat (Comptes Rendus, 29th Nov' 
1847), is of opinion that the insensibility or anaesthesia produced by the inhalation 
of ether, is due to an alteration in the qualities of the arterial blood, and that the 
degree of insensibility is in direct ratio to the extent of this alteration. In the de- 
tails of the present series of experiments, he states that on immersing the beak of 
a pigeon in a vessel containing chloroform, the bird fell down in 55 seconds, and 
became insensible. On withdrawing the apparatus it speedily recovered, and in 
two minutes flew away. In another experiment, in which Simpson's apparatus 
was used, a pigeon became insensible in one minute, but was immediately re- 
stored on holding a flask of ammonia under its bill. On wrapping a cloth soaked 
in chloroform around a rabbit's mouth and nose, the animal became insensible 
in three minutes. In another similar experiment, insensibility was induced in 



228 



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[July 



two minutes. In a third experiment, in which Simpson's apparatus was employed, 
insensibility resulted also in two minutes; the animal, indeed, was supposed to be- 
dead, but the application of ammonia to its nose speedily restored it. In another 
experiment, the rabbit's head was placed in a glass vessel containing about 16 
grains of chloroform at the bottom; free access of air between the sides of the glass 
and the animal's head was thus obtained. In two minutes the animal sank down, 
and insensibility speedily followed. On repeating this experiment with a double 
quantity of ether instead of chloroform, the animal sank down in three minutes; 
but the effects were much less powerful than with chloroform. Dogs became in- 
sensible in two minutes by inhaling chloroform from a sponge. In one experi- 
ment with a dog whose crural vessels and nerves were laid bare, the colour of the 
arterial blood became dark, like that of the vein, after one minute's inhalation ; 
and insensibility then ensued. On stopping the inhalation, the vessels resumed 
their ordinary colour. In another experiment of the same kind, the arterial blood 
assumed a brown colour in minutes. 

The observations which M. Amussat makes on cases in which chloroform was 
employed in the human subject are interesting only in so far as they demonstrate 
the more speedy production of complete insensibility by this fluid than in ether; 
and in showing that chloroform produces the same effect as ether on arterial blood, 
converting its colour and aspect into those of venous blood. He has never ob- 
served any injurious consequences to result from the employment of chloroform. 

From experiments performed upon himself and upon many other individuals, 
M. Gerdv* finds : — 

1. That chloroform, like ether, produces cough; but that its employment is in 
this respect tolerated better than ether. 

2. Applied to the nose and mouth by means of a sponge, it sometimes cauterizes 
the parts it touches; but this appears to depend on the chloroform being badly 
prepared. In such cases an inhaling apparatus should be employed instead of a 
sponge dipped in the liquid. 

3. The sugary taste which it produces is most perceived towards the isthmus 
faucium, the base of the tongue, the velum and anterior arches of the palate,, and 
in the pharynx. That the taste is perceived in the pharynx may be proved by in- 
haling the vapour only through the nose. The fact is physiologically interesting, 
in showing that the pharynx possesses the faculty of perceiving the flavour of chlo- 
roform when reduced to vapour. And it is so much the more remarkable, inas- 
much as in its liquid state chloroform causes so much irritation when applied to 
the tongue that this organ is unable to perceive its taste. 

4. Chloroform causes an increased flow of saliva, though in a less degree than 
ether. 

5. Chloroform more readily produces an inclination to vomit than ether: the 
latter is, therefore, preferred by some individuals. 

6. The numbness caused by chloroform often ensues more speedily than that 
produced by ether, though not invariably. 

M. JobertI has furnished the details of cases in which this new anaesthetic agent 
was employed with complete success. In one case amputation was performed 
at the thigh for diseased knee-joint. Before commencing inhalation the pulse was 
104, but when complete insensibility ensued (which it did in 1 minute 30 seconds), 
it fell to 72. No cough was excited by the inhalation, and respiration continued 
unimpeded during the continuance of the insensibility. The operation was per- 
formed without the least consciousness of pain, and at the conclusion of it, the 
patient roused up suddenly as from a profound sleep. The blood had lost some- 
what of its ordinary bright tint, but was not so deeply coloured as is observed to 
be the case after the inhalation of ether. In another case the operation of cataract 
by depression was performed with equally satisfactory results; complete insensi- 
bility and unconsciousness having been induced. The other two cases, which 
were quite successful, contain nothing else worthy of note. 

In an extract from a Memoir on the employment of Chloroform, M. SkbillotJ 
mentions the effects produced by this fluid on three of his pupils and one of his 



* Comptes Rendus, p. 803. 



f Op. cit., p. 806. 



J Loc. cit , p. 802. 



1848.] 



Ansesthetic Agents. 



229 



colleagues. In one. all power of movement was lost in 1 minute 30 seconds; in 
another, in 2 minutes; in the third, in 5 minutes; and in the fourth, in 6 minutes. 
In each, consciousness of what was passing around, was retained. They also 
perceived when they were touched, but it seemed to them as if they were enve- 
loped in a kind of atmosphere of insensibility towards pain. The power of motion 
and free exercise of the mind was not regained so speedily as after the inhalation 
of ether; the period being from 15 to 20 minutes in two of the individuals. 

In a subsequent memoir/* M. Sedillot remarks that more extended observations 
prove still more satisfactorily that chloroform, as Dr. Simpson says, possesses great 
advantages over ether, and will, most probably, quite replace it. The effects are 
usually more speedy in their onset, and more persistent in their duration. It is/ 
also employed with greater facility; the odour is agreeable to the patients; it pro- 
duces no cough, or sense of heat in the chest. During the insensibility the patients 
usually snore as in ordinary sleep. The pulse and respiration are usually a little 
accelerated. Another advantage of this fluid over ether is, that it is not exposed 
to the risk of exploding, like ether, when used by candle or lamp-light. 

More recently, some remarks have been published on the subject by M. Roux,f 
who speaks strongly in favour of this new agent for the alleviation of pain. He 
prefers sponge as the substance into which the chloroform for inhalation should be 
poured. He observes, that in all the cases he has seen, the anaesthesia was in- 
duced more speedily by chloroform than by ether. Complete insensibility ensued 
in from half a minute to a minute, or rather more. And there is economy of ma- 
terial as well as of time, for forty-six to sixty grains are usually sufficient for the 
purpose. In none of the cases which fell under his observation did the patients 
express any disrelish, or experience any of the symptoms of bronchial irritation 
which almost invariably attended the early inspirations of ether. In none was the 
state of insensibility accompanied by delirium or extraordinary hallucinations; 
neither was headache or any other uneasiness, which sometimes remains after 
the use of ether, ever complained of. Although the length of time during which 
the insensibility and anaesthesia continued varied in different cases, yet it would 
seem as if the duration of the effect was greater or less according as the impression 
was induced with less or greater rapidity. It is remarkable that when the patients 
awake out of the state of insensibility they do so at once, and not gradually. The 
patient does not always remain in a tranquil state when under the influence of 
chloroform, but is sometimes very restless; in one case it was almost impossible 
to restrain the movements of the patient so as to operate ; occasionally they are 
exceedingly loquacious. 

In allusion to the above observations of M. Roux, M. VelpeauJ remarked that 
lie had witnessed almost similar results from the employment of chloroform. In 
the experiments which he had witnessed, insensibility was induced by chloroform 
in from half a minute to 1, 2, 3, or more minutes; while ether usually requires 
from 5 to 10 minutes to produce its full effect; and the insensibility is less com- 
plete, and lasts for a shorter time with ether than with chloroform. M. Velpeau 
also recommends a sponge as the best apparatus for inhalation. During the same 
sitting of the Academy, M. Dumas also added his testimony to the efficacy of this 
new agent. 

M. Boyer§ speaks of the advantages of employing chloroform in operations 
about the eye. Having operated for strabismus and cataract on several dogs while 
under the influence of it, he states that the eye during the whole time remained 
quite motionless. 

M. BlanchetII remarks that, inasmuch as the colour of arterial blood is always 
more or less altered in persons or animals under the influence of the vapour of 
chloroform, it would be desirable, in cases where the inhalation has been carried 
too far, to act upon the kind of asphyxia produced, by the inhalation of a mixture 
of gases richer in oxygen than the air of the atmosphere is : he says that such a 
view is substantiated by the results of his experiments on animals. — -London Med. 
Gaz., Feb. 1848. 



* Comptes Rendus, 6 Decembre. f Op. cit., 13 Decemhre, p. S87. 

| Loc. cit., p. 890. § Loc. cit., p. 903. 

II Loc. cit., 20 Decembre. 



230 



Progress of the Medical Sciences. 



54. Narcotism from Inhalation of Vapours. — Dr. Snow, in a paper read before the 
Westminster Medical Society, April 29th, 1848, related the result of a great number 
of experiments that he had performed on animals, for the purpose of determining 
the proportion of various vapours in the blood in the different stages of insensibility. 
He had ascertained that the quantity of vapour in the blood, necessary for causing 
any particular degree of narcotism, bore a constant relation to the quantity that the 
blood would dissolve, and that this relation was the same with respect to the dif- 
ferent substances that he had examined, including chloroform, ether, bisulphuret 
of carbon, and others. For producing the second degree of narcotism, in which 
there were loss of consciousness, and impairment of voluntary motion, one fifty- 
sixth part of what the blood would dissolve was sufficient; and for producing the 
fourth degree, or that state in which all motion of the voluntary muscles was com- 
pletely abolished, one twenty-eighth part was required. The experiments for 
determining these points consisted in ascertaining the smallest quantity of vapour, 
in proportion to the air, which would suffice to induce a given effect, and were 
performed in the following manner: — A small quantity of the liquid to be ex- 
amined was weighed, and put into a very large glass jar, carefully closed, and 
when the vapour was equally diffused, a small animal — generally a bird or a 
mouse — was introduced, which was allowed to remain for a short time after the 
effects of the vapour had ceased to increase. At the point at which the effects 
became stationary, the tension of the vapour in the blood balanced the tension of 
that in the air in the lungs, at the temperature of the body, which being already 
known, the quantity in the blood could be calculated. The results obtained agreed 
with experience as to "those vapours which had been administered to patients. 
Chloroform required about 288 parts of seram of the blood to dissolve it ; and tak- 
ing M. Valentin's calculation, that the human body contains, on an average, about 
twenty-six pounds of serum, it was found that twenty-four minims was the twenty- 
eighth part of the quantity the blood would take up — the quantity, consequently, 
for producing complete insensibility. When allowance was made for the vapour, 
which reached no further than the trachea, and was therefore not absorbed, this 
agreed with experience. The quantity of ether required was found by calculation 
to be considerably larger, on account of its much greater solubility; and these ex- 
periments showed the cause of the rule he had stated on another occasion, that the 
more soluble a volatile substance was, the greater was the quantity required to 
produce a given effect; and that, consequently, when the volatility was taken into 
account, the strength of this class of substances was in the inverse ratio of their 
solubility. He considered that the vapour of these substances did not become de- 
composed, or enter into any chemical combinations in the body, but produced its 
effect by its mere presence, impeding those combinations between the oxygen in 
the arterial blood and the nervous tissues, on which the functions of the nervous 
system depend. — Lancet, May 13, 1848. 

55. Action of Chloroform on the System.— Francis Sibson, Esq., in an interesting 
paper in the London Med. Gaz., Feb. 1848, remarks: — "Chloroform, ether, and 
alcohol, are closely allied, both as anaesthetic agents and as narcotic poisons. In 
small repeated doses they produce agreeable exhilaration and pleasing hallucina- 
tions. A friend informs me that he has frequently produced, by merely inhaling 
chloroform from a bottle, the most delightful thrill over his whole frame. These 
narcotics, carried by the blood into every capillary, excite simultaneously every 
part of the frame. The action on the capillaries themselves is universal ; they 
enlarge and are distended with blood, which now circulates through capillaries 
previously invisible. The conjunctiva becomes injected, and the lips and cheeks 
are turgid. The secretions are consequently increased, the eyes become watery, 
and saliva collects in the mouth; while the visible capillaries are turgid, the 
capillaries in the brain, the lungs, and other viscera, are turgid likewise. 

" Turgidity of the capillaries is an effect characterizing the narcotic poisons. 
Alston observed this in frogs poisoned by opium. I dipped the limb of a frog into 
a watery infusion of opium; all the capillaries of the limb were soon injected with 
blood. Mr. Nunnely has noticed the remarkable reddening from the distension 
of the capillaries produced by prussic acid. Stramonium, hyoscyamus, and bella- 
donna, often excite universal redness of the skin. The experiments of Mr. Wak- 



1848.] 



Anaesthetic Agents. 



231 



ley show that ether and chloroform cause distension of the capillaries in the lungs 
and other internal organs. 

a The action of chloroform, ether, and alcohol, pervades the whole frame. In 
the first stage the excitability of every organ and fibre is exalted, but throughout, 
their marked action is upon the brain. Exhilaration is followed by excitement, 
excitement by cerebral disturbance. At this stage the person affected revels in 
the absurdities of social intoxication: consciousness still exists, but it is deranged. 
The mind is intent in its own way on many things, but does not now observe all 
personal realities. The mind often at this stage does not feel pain, simply because 
it is intently taken up with other things, just as a man in battle often does not feel 
a wound. This stage of deranged consciousness is also that of staggering intoxi- 
cation, the muscular power and control being enfeebled, and sensation blunted. 

'•'This stage of cerebral excitement and disturbance is speedily followed by the 
stage of cerebral sleep. There is unconsciousness, but not coma; the person 
sometimes can be roused, the eye turns up as in sleep, and the iris contracts. 
Now in all persons free from cerebral disease the pupils contract during sleep. I 
have opened the eyes of many sleepers, and, the brain being sound, I invariably 
found the pupils contracted. The sounder the sleep the smaller the pupil. In all 
persons the pupil dilates as soon as they awake, and if their sleep be sound the 
dilatation is gradual." 

"Under the influence of ether and chloroform,' 7 he further observes, " the pupils 
first contract, then oscillate between contraction and dilatation, and finally dilate. 
So long as the pupil is contracted a dreamy state often exists, and the patient, 
when operated upon, frequently manifests an unremembered consciousness; he 
is, in fact, in the state of sopor. When the pupils dilate, and the iris is immove- 
able, consciousness is extinguished, and the patient is in the state of coma." 

The stages of the increasing influence of chloroform, ether, and alcohol, are, 
according to Mr. Sibson : — 

11 Cerebral excitement. 

11 Cerebral derangement; staggering intoxication. 

" Cerebral sleep (sopor) ; pupils contracted; dreams; reflex functions of brain 
and spinal marrow still active. 

" Cerebral death (coma) ; reflex functions of medulla and spinal marrow still 
active. 

u Death of spinal marrow; cessation of respiration (heart's action still generally 
present). 

" Cessation of heart's action. 

11 It is very important to be able to tell easily when the stage of safety, sopor, is 
about to emerge into that of danger' — coma. The action of the pupils is the key 
to this knowledge. Chloroformization ought not to be continued one instant after 
the pupils, previously contracted, have begun to dilate. If unconsciousness can 
be secured by sopor, the inhalation should not be carried on to produce coma. 

" If complete muscular relaxation be sought for, as in hernia to facilitate taxis, 
in dislocation to make reduction easy, and in tetanus, then it will be needful in 
general to urge the patient from sopor into coma, but as soon as the muscular re- 
laxation is secured the inhalation should cease. 

" When chloroform or ether is employed in chorea, delirium tremens, or other 
affections, it should never be urged beyond sopor. In neuralgia it is not usually 
needful to produce unconsciousness. Whenever the pain disappears the inhala- 
tion ought to cease. 

" Dr. Snow has made this important observation, that the effects of chloroform 
and ether increase after the administration of it has ceased: this he calls the cumu- 
lative property of those vapours. This increase of effect he has observed to last 
for twenty seconds. Mr. Wakley, in his experiments, observed the same thing. 
I observed this effect the other day in a woman whose lip was extensively pared 
under the influence of chloroform. I gave up the employment during sopor, the 
pupils being still contracted; and in a few seconds coma supervened, the pupils 
being permanently dilated. 

"On this ground, Dr. Snow objects to rapid chloroformization. He conceives 
that the complete effect ought not to be gained in less than two minutes. I own 
I cannot see how a slow, but effective administration of the vapour, can lessen 



232 



Progress of the Medical Sciences. 



[July 



the clanger arising from the still increasing effect after the administration has 
ceased. The longer the inhalation is continued, the greater the total amount of 
chloroform received into the system; and this chloroform, already circulating in 
the blood, will still, I conceive, under either circumstance of quick or slow inha- 
lation, continue to produce an increased effect. Indeed, in the case in which I 
observed this action, the inhalation had been carried on with intermission some 
minutes. In another case, in which unconsciousness was produced quickly, the 
pupil, which had been dilated during one or two seconds, contracted immediately 
after the cessation of the inhalation. 

" I think, with my friend Mr. Fearn, that it is important to dilute the chloroform 
vapour largely with air during the first few inhalations, so as to avoid the sudden 
shock on the nerves of the lungs, and accustom them to its presence." 

56. Mode of Administering Chloroform. — Prof. Simpson states that he believes, in 
surgery the symptom most to be relied upon as indicating a thoroughly anaesthetic 
state, was slowness of respiration, or a degree of snoring, or stertorous breathing. 
After the appearance of this symptom, it is only needful to continue the inhalation, 
from time to time, by intermissions; and, by repeated applications of the hand- 
kerchief, the patient ought to be kept in the same sopor during the whole of the 
operation. In midwifery, Dr. S. believed that this deep degree of anaesthesia was, 
in ordinary circumstances, not required. He had found that, when administered 
so as to cause stertorous breathing, the uterine contractions generally ceased, and. 
did not return till the effect had, in some degree, passed off. He had found, 
therefore, that the chloroform given in a surgical dose was very useful whenever 
he wished to stop the uterine contractions, as in cases where turning was necessary, 
and many other obstetric operations. In cases of natural labour, he generally 
began with a large dose of chloroform, so as to bring the woman at once com- 
pletely under its influence. This mode of proceeding prevents the chance of any 
excitement; and, although it occasionally may stop the pains for a few minutes, 
especially if the labour is still in an early stage, yet the contractions recur as soon 
as the deeper state wears off, which it usually does in two or three minutes. The 
depth of the sopor is allowed to diminish by merely withholding the handkerchief 
till a pain comes on; and then the anaesthetic state is kept up by its reap plication, 
for two or three inspirations every four or five minutes ; or what is better, with 
each succeeding pain. The patient should be kept unconscious, but not deeply 
so, till the head was passing the vulva, when a deeper anaesthesia was required. — 
Proceedings of Edinburgh Obstetrical Society, in Monthly J. and R. Med. Sci., April 
1848. 

57. Notes on the Anaesthetic Effects of Hydrocarbon, Nitrate of Ethyle, Benzin, Alde- 
hyde, and Bisulphurct of Carbon. By J. Y. Simpson, M. D. — Chloride of Hydrocarbon, 
or Dutch liquid, as it is often termed in consequence of it being first discovered by 
the Dutch chemists of the last century, is one of the various fluids to which the 
name of chloric ether was for some time given. 

When equal parts of olefiant gas and chlorine are mixed together, the two gases 
rapidly disappear, and produce a colourless oily liquid, of a peculiar sweetish 
taste and ethereal odour. Its specific gravity is 1-247. It boils at 148°. It is 
composed of four atoms of carbon, four of hydrogen, and two of chlorine. Hence 
its formula is C 4 H 4 C1 2 . 

When its vapour is inhaled, the chloride of hydrocarbon causes so great irrita- 
tion of the throat, that few can persevere in breathing it for such a length of time 
as to induce anaesthesia. I have latterly, however, seen it inhaled perseveringly 
until this state, with all its usual phenomena, followed; and without excitement 
of the pulse, or subsequent headache. When I myself attempted to inhale the 
chloride of hydrocarbon, it produced an extreme degree of acrid irritation in the 
throat, which did not disappear entirely for many hours afterwards. 

Nitrate of Ethyle. — When two parts of alcohol, and one part of pure nitric acid, 
are distilled together, with the addition of a small quantity of urea, nitrate of ethyle, 
or, more properly, nitrate of oxide of ethyle, is produced. It is a transparent colour- 
less liquid, with a sweet taste, and very agreeable odour. Its specific gravity is 
1-112; it boils at 185°. It i#a compound of four proportions carbon, five of hy- 



1848.] 



Anaesthetic Agents. 



233 



drogen, six of oxygen, and one of nitrogen; and its formula is, (C 4 H.) 0,N0 5 ; 
or AcO,N0 5 . 

Nitrate of ethyle is easy and pleasant to inhale, and possesses very rapid and 
powerful anaesthetic 'properties. A small quantity, such as fifty or sixty drops, 
when sprinkled on a handkerchief and inhaled, produces insensibility after a few 
inspirations. But during the brief period which elapses before the state of com- 
plete anaesthesia is induced, the sensations of noise and fulness in the head are 
in general excessive; and much headache and giddiness have usually followed 
its employment, and persisted for some time. . 

Benzin or benzole was first discovered by Farraday, as one of the products in his 
experiments on compressing oil gas, and was designated by him bicarburet of 
hydrogen. Mitscherlich afterwards obtained it by distilling, at a high temperature, 
benzoic acid with an excess of slaked lime. 

It is a clear colourless liquid, of a peculiar ethereal odour; with a specific 
gravity of 0-85; and boils at 186°. It is believed to be composed of two propor- 
tions of carbon and one of hydrogen. Its formula is, C 2 H; or perhaps, more 
properly, C 12 H 6 . It is polymeric with the hypothetic radical formyle. 

In my experiments with benzin I found it capable of producing anaesthesia ; 
but the ringing and noises in the head accompanying and following its inhalation, 
were so excessive, and almost intolerable in the case of myself and others, as to 
seem to us to render its practical applications impossible, even had there been no 
other objections to its use. Latterly, Dr. Snow has tried its employment upon 
some patients for tooth-drawing; and in one instance of amputation. In this last 
case it produced convulsive tremors. — Lancet, Feb. 12, 1848. 

Aldehyde, or hydrate of oxide ofacetyle, was first noticed by Doebereiner in distilling 
together sulphuric acid, alcohol, and peroxide of manganese; but it was left for 
Liebig to fix and determine everything about its chemical nature. It is a colour- 
less limpid liquid, of specific gravity 0-791. It is very volatile, boiling at 72°. It 
spontaneously changes when long kept, and is converted into two substances, a 
solid and a fluid, metaldehyde and elaldehyde. Liebig found it to be composed 
of four atoms of carbon, four atoms of hydrogen, and two of oxygen ; and its 
formula is C 4 H 3 0+aq. 

Professor Poggiale, of Paris, has lately made some experiments with dogs on 
the inhalation of the vapour of aldehyde, and from these has concluded that its 
anaesthetic effects will be found more prompt and energetic than those of sulphuric 
ether or chloroform. It certainly possesses, like some of the preceding agents, 
well-marked anaesthetic properties ; but it assuredly will never come into use, as 
very few will be found capable of inhaling a sufficient dose of its vapour. In 
fact, out of five of us that attempted to inhale aldehyde, very carefully prepared 
and purified, four were driven to suspend the respiration of it in consequence of 
the coughing and insufferable feelings of dyspnoea which it immediately induced. 
The sensations of difficult respiration and constriction in the chest which the 
vapour produced, resembled precisely those of a severe fit of spasmodic asthma. 
In the fifth case, the experimentalist, a*fter perseveringly breathing the aldehyde 
for a minute or two, became entirely insensible; the state of anaesthesia lasted for 
two or three minutes; during it, the pulse became excessively small and feeble. 
On recovering, the bronchial constriction and coughing, which had disappeared 
as the anaesthesia was induced, returned immediately, and was annoying for 
some time. 

Bisulphuret of carbon, or alcohol of sulphur (as it was at first termed), was acci- 
dentally discovered in 1796 by Lampadius, when experimenting on iron pyrites. 
Different opinions of its composition were held by different chemists : but Berze- 
lius and Marcet, in 1813, at last fully confirmed the previous idea of Clement and 
Desormes, Vauquelin, &c, that it consisted only of sulphur and carbon. It is 
composed of two atoms of the former to one of the latter; consequently its formula 
is 0s 2 . 

The most easy method of procuring it is by transmitting the vapour of sulphur 
over fragments of charcoal heated to redness in a closed porcelain or iron tube. 
The resulting bisulphuret of carbon, when purified by distillation, is a clear, co- 
lourless liquid, of a pungent taste. Its specific gravity is 1-272. It is very vola- 
tile, boiling at 108°. 



234 



Progress of the Medical Sciences. 



[July 



It has been stated in various literary journals, that bisulphuret of carbon has 
lately been used as an anaesthetic agent at Christiana; but no particulars regarding 
its employment in Norway have, as far as I know, been yet published. 

I have breathed the vapour of bisulphuret of carbon, and exhibited it to about 
twenty other individuals, and it is certainly a very rapid and powerful anaesthetic. 
One or two stated that they found it even more pleasant than chloroform; but in 
several it produced depressing and disagreeable visions, and was followed for 
some hours by headache and giddiness, even when given only in small doses. 
In one instance I exhibited it, with Mr. Miller's permission, to a patient, from 
whom he removed a tumour of the mamma. It very speedily produced a full 
anaesthetic effect; but it was difficult to regulate it during the operation. The 
patient was restless in the latter part of it ; but felt nothing. Like several others 
when underwit, her eyes remained wide open. After the operation she was ex- 
tremely sick, with much and long-continued headache ; and, for fifty or sixty 
hours subsequently, her pulse was high and rapid, without rigor or symptoms 
of fever. 

I tried its effects in a case of midwifery, in presence of Dr. Weir, Dr. Duncan, 
Mr. Norris, and a number of the pupils of the Maternity Hospital. It was em- 
ployed at intervals during three quarters of an hour. The patient was easily 
brought under its influence, a few inspirations sufficing for that purpose; but it 
was found altogether impossible to produce by it the kind of continuous sleep 
attending the use of chloroform. Its action was so strong, that when given, as a 
pain threatened or commenced, it immediately affected the power of the uterine 
contractions, so as often to suspend them; and yet its effects were so transient 
that the state of anaesthesia had generally passed off within a minute or two after- 
wards. The patient anxiously asked for it at the commencement of each pain. 
During its use she was occasionally sick, and vomited several times. Latterly 
her respiration became rapid, and her pulse rose extremely high. I then changed 
the inhalation for chloroform, and, under it, the patient slept quietly on for twenty 
minutes, when the child was born. During these twenty minutes there was no 
more sickness or vomiting, and the pulse gradually sunk down to its natural 
standard; and a few minutes after the child was expelled, and while the mother 
still slept, her pulse was counted at 80. Next day the mother and infant were 
both well, and she has made a good recovery. 

While these experiments prove the strong anaesthetic properties of bisulphuret 
of carbon, they at the same time show its disadvantages. I have not alluded to 
another strong drawback upon its use, viz., its very unpleasant odour. "It has 
(says Dr. Gregory) a peculiarly offensive smell of putrid cabbage." — (Outlines of 
Chemistry, p. 130.) By dissolving various essential oils in the bisulphuret I tried 
to overcome this disagreeable defect, but without much success. 

None of the five anaesthetics which I have mentioned in the present communi- 
cation are, I believe, comparable with chloroform or sulphuric ether, either in 
their manageableness or in their effects. And the after consequences which all 
of them tend to leave, are too severe and too frequent to admit of their introduc- 
tion into practice. They are more interesting physiologically than therapeutically. 
•—Month. Journ. and Ret. of the Med. Sciences, April 1848. 

58. Reckless Employment of Chloroform in a case of Delirium Tremens. — [The fol- 
lowing case affords an example of the reckless use of chloroform which can hardly 
be too strongly reprobated. The patient fortunately escaped. Had the result been 
different, and the case been submitted to a jury of intelligent men, they would, 
we conceive, have had little difficulty as to a verdict.] 

The patient was labouring under a third attack of the disease, and as he had 
been cured in the two previous instances with opium and morphia, the narrator 
states, "I had recourse to the same at this time also, and I almost night and day, 
for two days and two nights, continued giving him small repeated doses, and in- 
creasing it as much as I durst venture. There was no appearance of sleep for 
nearly three days and nights, but all the symptoms were aggravated. He became 
quite unmanageable, and required two or three persons to keep him in bed. The 
whole body, especially the hands, were in a constant tremor ; cold clammy sweats 
bedewed his skin, and the phantoms which assembled around his bed to disturb 



1848.] 



Anaesthetic Agents. 



235 



his rest were innumerable. As he had occasionally slight convulsive fits. I was 
afraid to go on any further with the opium. I determined to try the chloroform, 
although I did not consider him a very good subject for it. I procured an ounce 
from a large medical establishment in the city, where I was sure I would get it 
genuine. 

11 1 began by pouring ten to twenty drops on a handkerchief, and holding it over 
his mouth and nose, and always renewing it when required. He became furious 
after breathing it about two minutes, and struck and attempted to bite me, when I 
was obliged to desist until I got his hands secured, and a strong man in the bed 
to secure him. I then went on for nearly half an hour, always pouring on a little 
more occasionally, and he talking incessantly, and endeavouring to disentangle 
himself and get up. At last he began to snore occasionally for a minute, his eyes 
became fixed and staring, the pupils much contracted ; slight convulsions came 
on, and began to increase to such a degree that I was obliged to take the hand- 
kerchief from his face, and allow him to breathe the free air. He soon recovered, 
and began again to get furious. I was anxious to persevere as long as I could 
with safety. I repeated the drops, and applied chloroform again; and, when 
nearly a whole hour had elapsed, and my hand scarcely three minutes from his 
face, holding the handkerchief the whole time, the convulsions commenced again, 
and colliquative sweats were now pouring over his face, which was quite cold to 
the feel. I got alarmed, and gave up the experiment. During the hour he had 
inhaled rather more than gvi. of the chloroform. He soon recovered from the bad 
symptoms, but it was now late in the evening, and my patience was exhausted. I 
therefore thought I would leave him until the morning. There remained in the bot- 
tle rather more than a drachm of the chloroform. I told his keeper just to put a few 
drops on the handkerchief occasionally, and keep it to his nose until he got it all. 
I called in the morning: he had become very quiet and dull after I left him, and 
a few hours afterwards had fallen sound asleep. He was sleeping when I called, 
I felt his pulse, but did not wake him : his pulse was good, 72. On the next 
morning I found that he had slept well, and he asked me whether it was the opium 
or the chloroform which had set him asleep. He recovered very rapidly, and was 
soon able to resume his usual avocations." — Lond. Med. Gaz., March 1848. 

59. Use of Chloroform in Tetanus. — Mr. R. L. Baker (Prov. Med. and Surg. Journ., 
May 31) administered chloroform in a case of tetanus supervening on the fifth day 
after an injury of a finger, in which the first phalanx was torn off. The spasms 
were relaxed under the effects of the remedy, which was kept up for three quar- 
ters of an hour. The patient continued to improve for eight days, at the end of 
which, as there was a threatening of return of the tetanic symptoms, Mr. B. am- 
putated the finger, and the patient at the date of the report was rapidly recovering. 

Dr. C. A. Worthington of Lowestoft, relates {Prov. Med. and Surg. Joufn.. April 
19) a case of acute traumatic tetanus in a boy 17 years of age, in which the chlo- 
roform was administered with striking relief. But the spasms returned and the 
case terminated fatally, though the remedy was industriously persevered in. 

60. Chloroform in Neuralgia. — Mr. Sibson relates (Lond. Med. Gaz., March 31, 
1848) six cases of facial neuralgia, in which he administered chloroform. In five, 
pain speedily gave way, but in two unpleasant effects were produced. In one^ 
sickness, giddiness, and some headache : in the other there was great aggravation 
of headache, deafness, increased cough, &c. 

Mr. Moffit has also used it (Lond. Med. Gaz.) twice in a case of severe neuralgia 
of the neck, and on both occasions it brought on severe hysterial fits and vomiting 
to a great degree, which made it necessary to desist. The pain was not in the 
least relieved, and the patient felt worse in every respect for several days. 

61. Chloroform in Dysmenorrhea. — Dr. J. Henry Bennet (Lancet. Feb. 19, 1848) 
states, that he has found the chloroform a valuable therapeutic agent in dysme- 
norrhcea. 

[In one case of very severe and intractable dysmenorrhea in which its use was 
resorted to at our suggestion, it produced such distressing effects that the practi- 
tioner who administered it could not be tempted, he informs us, to try it again.] 



236 



Progress of the Medical Sciences. 



[July 



62. Chloroform in Midwifery Practice. — Dr. Nevins, in a paper read before the 
Liverpool Medical Society, states that he has reports of about eighty cases of labour 
under the influence of this agent, the general result of which was highly -favour- 
able. No case of death has reached him in which this termination could be attri- 
buted with any fairness to it. One woman had died of puerperal fever on the 
third day after its employment, and a second patient had also died about the same 
date with sloughing of the os uteri and interior of the uterus, after the application 
of the short forceps ; but he had ascertained that at the same time one or two 
cases of puerperal fever had occurred in the practice of surgeons who had used 
chloroform, and erysipelas was also prevalent in the town at the same time. Now 
it has been often observed, that when the latter disease is prevalent, cases of puer- 
peral fever were also met with; and there was, therefore, no presumption that the 
occurrence of the fever had any connection with the employment of the chloro- 
form. Another patient had been affected with cedema of the epiglottis, commen- 
cing about twenty-four hours after labour, in which she had cried out a good deal 
prior to the exhibition of the chloroform, but not so much as many women in 
ordinary labour. Here, then, a presumption might arise that the oedema was 
owing to the inhalation, but further experience was necessary to confirm or dis- 
prove it. Another patient began to rave violently after the inhalation, but she had 
been previously much excited by the number of persons around her, (students 
and others,) who had questioned her frequently while preparing for its adminis- 
tration, and when just beginning to be under its influence: she ultimately did 
well. Another young woman with her first child, to whom ether was given, 
which was afterwards ascertained not to have been of the full strength, had severe 
convulsions, beginning about ten hours after labour was completed. By bleeding 
and the common treatment she was cured in the ordinary length of time. 

With these exceptions, no untoward circumstances had occurred after the use 
of the chloroform ; and it was evident that any connection, except that of time, 
between some of these and its employment was very doubtful. 

The general description of the labours was, that the patients accomplished them 
in the usual time, but without the fatigue of ordinary parturition, and that they 
were entirely free from the exhaustion so commonly experienced afterwards : 
they expressed themselves as if the labour had scarcely been of any consequence, 
and the recoveries, with the above exceptions, were all described as '''unusually 
quick and favourable. ;? In many, perhaps most cases, the after-pains were de- 
cidedly less than usual, or than they had been in previous labours. In several, 
however, they were as severe as usual, in none more so. If administered prior 
to the dilatation of the os uteri, no particular effect was noticed upon it; but when 
the vagina was hot, dry, and swollen, as in some of the cases, it generally became 
soft and moist almost immediately. In about one-third of the cases the uterine 
contractions were decidedly enfeebled, and the intervals lengthened j but so much 
relaxation of the soft passages was produced at the same time, that, with one or 
two exceptions, the labour was not reported as having been prolonged beyond 
what might have been anticipated had chloroform not been used. In nearly every 
instance the abdominal muscles acted in concert with each uterine contraction, 
and the legs were generally stretched out at the same time, and the patients often 
uttered a low moan during each pain, but without being subsequently conscious 
of having suffered. In many cases they were aware of the passage of the child's 
head over the perineum, but it was unaccompanied with pain. The placenta 
was expelled as usual, and there was less hemorrhage than common in most of 
the reports ; our experience, therefore, is so far decidedly in favour of the safety 
and utility of its employment. In one case it was continued at intervals for six- 
teen hours and a half, in another for eleven and a half, and in others for varying 
periods down to ten minutes, just during the passage of the head over the peri- 
neum.— Lond. Med. Gaz., March 1848. 

63. Injurious Effects of Chloroform. — Dr. Nevins, in a paper read before the 
Liverpool Medical Society, on the 3d of Feb. last, 11 on the present state of our 
knowledge with respect to the use and effects of chloroform," states that he has 
received private communications up to that date from several of the London hos- 
pitals, from Edinburgh, the Liverpool hospitals, and from Leeds and Birmingham, 



1848.] 



Anmsthetic Agents. 



237 



the York Lunatic Asylum and Retreat, the Wakefield Asylum, Dr. Conolly, Dr. 
Churchill, and other private sources, besides the cases recorded in the public jour- 
nals; and, from the candid tone of the letters, and the particulars contained in 
them, he thought the Society might consider itself in possession of the unfavoura- 
ble effects and results of this agent, as well as its favourable ones. He should, 
however, chiefly dwell upon the former, as they were the most important at 
present towards obtaining a. full knowledge of its properties; the reports in the 
journals having fully proved that it may be advantageously administered in many 
instances, and having confirmed the utility of its employment in most of the cases 
in which ether has hitherto been used. 

Vomiting.— Amongst the immediate effects produced by its administration, 
vomiting was frequently present. It often seemed dependent upon the food 
having been recently taken; but in several instances neither food nor drink had 
been swallowed for several hours previously. It was, however, very important 
to attend to this particular, as in several cases chloroform had produced no effect 
whatever when inhaled even in large quantities immediately after a full >neal. 

Headache was anoihernot unfrequent result, though the contrary had often been, 
stated. In some cases this continued for several hours, and in one instance it had 
not entirely disappeared after some days. It was principally, if not entirely, con- 
fined to the forehead. 

Convulsions were very frequent, and lie used the term "very" advisedly, be- 
cause they had been often reported to him. In one or two reports it was said, 
" Nearly all the patients operated upon were more or less convulsed ;" and in 
some instances this had rendered the operation almost impracticable. In a case 
of tying the brachial artery, the muscles of the arm were so violently affected that 
the vessel could scarcely be gained, and the accompanying veins were so swollen 
and turgid as to obscure it even when exposed — rendering the operation very un- 
satisfactory. In another case — an operation upon the perinseum — the urethra and 
other parts were so forcibly and suddenly retracted several times as to remove 
them from the control of the operator; and in a third case — one of lithotomy — it 
required the vigorous efforts of four persons to hold the patient on the table even 
after being tied up in the proper position. Several other cases had been men- 
tioned ; and, though he could not give an accurate statistical report, he thought 
about one patient in six or eight was affected with them more or less severely. 
In many cases they were accompanied by frothing at the mouth, whilst in others 
they resembled common hysterical symptoms. One important caution to be 
learnt from this was, never to attempt any operation more severe than tooth- 
drawing without having an assistant at hand. He had lately been prevented from 
completing an operation satisfactorily, by the patient starting up in the middle of 
it. in a state of excitement almost resembling that produced by laughing-gas, and, 
before he could be replaced on the sofa, the effects of the chloroform had quite 
gone off, and the operation was finished whilst the patient w r as conscious. He 
was not aware that he had started up or exhibited any degree of violence. It 
was sometimes supposed that convulsions only occurred before the full effect of 
the chloroiorm had been produced ; but in many of the reports it was distinctly 
specified that "the patient was fully under its influence," and this had been the 
case in his own instance. It was fortunate, however, that these convulsions 
scarcely ever commenced during the operation : they were always manifested as 
soon as the agent began to take effect, if they were present at all; and therefore a 
"surseon was not liable to be betrayed into commencing an operation during their 
absence, and being interrupted by their subsequent appearance. If they were so 
severe as to interfere with the operation, he had nothing to do but to wait till the 
effects of the chloroform had gone off, and then his patient was in no less favoura- 
ble a state than if he had simply not known of or used that agent; and he might 
remark, that not a single instance had been reported to him, or publicly recorded, 
in which any permanently injurious effects had resulted from these convulsions. 
Except as a matter of inconvenience, the clenching of the teeth often observed 1 
prior to tooth-drawing did not deserve particular notice. 

Depression or Prostration. — This was generally produced, more or less, and 
sometimes to an alarming degree, though hitherto no fatal issue had been traced 
to the emplovment of chloroform. It generally diminished the number of pulsa- 
No. XXXI.— July, 1848. 16 



238 Progress of the Medical Sciences. [July 

lions, and in one or two instances both the heart and lungs had almost ceased to 
act. and fears were entertained that the patients would die under the operation,, 
but they had rallied, and had all done well ultimately. In most cases the reports 
staled that reaction had been perfect in from ten minutes to two hours; and. so 
far as our present knowledge extended, the depression produced was not of an 
alarming or dangerous nature. In one or two cases, indeed, in which the patients 
were reported to have been at death's door, and pulseless, from uterine hemor- 
rhage, or prostration otherwise induced, they rallied under the influence of the 
chloroform, and the operations were safely performed, though ordinary stimulants 
had been previously tried in vain. 

Secondary Hemorrhage. — One of the reports says that the writer fancies there has 
been a greater disposition to secondary hemorrhage than in cases in which chlo- 
roform has not been used • but he is the only observer who has noticed this. The 
reports generally made, are, 11 Very trifling hemorrhage," " No secondary hemor- 
rhage," &c, and in the midwifery cases this was very striking. In several in- 
stances in which there was previously a disposition to flooding, there was none 
when chloroform was used; or without any previous flooding of a serious charac- 
ter, the reports state — "Very little discharge," or " Less hemorrhage than usual." 
The result of experience thus far is therefore in favour of this agent, as regards 
this particular effect. 

Excoriation of the lips and nose had generall y been stated to be caused by using 
an impure specimen ; but it had also been observed in so many cases in which 
every care had been taken to have pure chloroform, that it must be considered as 
an effect of the agent itself. It may, however, be prevented by taking care to 
avoid direct contact. 

Several cases of death at periods varying from twenty-four hours to two or three 
days, were mentioned in the reports from which Dr. Nevins derived his informa- 
tion ; but unfortunately they were nearly all cases of operation for hernia, or upon 
the abdomen in some way, and peritoneal symptoms had been chiefly sought for, 
whilst the state of the brain was not once alluded to, and that of the lungs very 
slightly in only one or two, and in these no mention was made of great congestion. 
In one respect the experiments of Mr. Gore were particularly interesting in their 
bearing upon midwifery. He killed a rabbit which was nearly at the full period 
of utero-gestation, by the repeated inhalation of chloroform vapour, and then ex- 
tracted six young ones from the uterus of the mother, which all lived for several 
minutes. Dr. Nevins had been struck by the few cases of still-born children in 
the midwifery reports sent to him. He had the particulars of about eighty cases 
of labour in which chloroform or ether was administered for periods varying from 
ten minutes to sixteen hours and a half, of which eighteen were cases requiring 
turning or instrumental assistance. Six children only were still-born ; of these, 
two had undergone craniotomy; one was a funis presentation; one was turned 
for placenta prsevia; and the other two were restored by appropriate treatment. 
In fact, it appeared as if the child had a better chance of life after the employment 
of chloroform than without it, as it was usual to have a greater number of still- 
born children with such cases as had been reported. 

From the experiments of Mr.Gruby, it appeared that the uninterrupted inhalation 
of chloroform for from three to five minutes caused death in several of the animals 
experimented upon; whilst similar animals breathed the vapour for upwards of an 
hour and a half, without injury, if occasional draughts of unmixed atmospheric air 
were interposed; from which the important inference might be drawn, that we 
ought, in every case of its administration, to remove the sponge occasionally, and 
allow the patient to inspire pure air alone. 

The statement that the vitality of the blood was impaired by ansesthetic agents 
was not borne out by facts ; for in Dr. Snow's report of ether cases he says the 
blood coagulated firmly in every case, and the jets of blood from divided arteries 
had the usual vermilion colour. This was observed in many of the reported 
cases, whilst in one or two the colour was said to be "'perhaps not quite so light 
as usual, but the venous blood was not so dark :" and in a rabbit killed by chloro- 
form, Mr. Gore found that the blood drawn from the jugular and crural veins just 
before death, coagulated quickly and firmly.— Lond. 'Med. Gaz.. March. 1848. 



1848.] 



Medical Jurisprudence and Toxicology. 



239 



64. Injurious Effects of Chloroform in Midwifery Practice. — Dr. Reed, during the 
discussion of a paper read by Mr. Brown before the Westminster Med. Society, 
on the use of chloroform, said: — " He was sorry that only favourable cases in which 
chloroform had been used had been published. No doubt it produced good effects 
in some cases, in others bad effects. In one institution in London it had been em- 
ployed in all cases. In one instance a strong, healthy woman, the mother of several 
children, had been seized with hemiplegia six or seven days after the use of chlo- 
roform. It had been noticed, too, that there had been more still-born children 
since the use of chloroform than previously. Some of these presented a peculiar 
state of the fluids; fluid had been extravasated under the skin. An eminent physi- 
cian who had visited the institution to see the effects of chloroform, had been pre- 
judiced against it; the child in this case was born in a 'tipsy state.' Though no 
such cases were published, yet in private we were hearing often of the unfavourable 
effects of chloroform. Thus in one case in which the patient had been in labour 
for forty-eight hours, she was kept under the influence of chloroform for twenty- 
eight hours— the child was still-born. In another case it was given for neuralgia 
to a lady lately delivered, and it proved fatal. What was the experience of mem- 
bers of its unfavourable effects'? In difficult and turning cases he should always 
himself give chloroform, but not in natural cases, unless there was some good, 
reason for its use." — Lancet ) April 29, 1848. 

65. Violent Convulsive Movement caused by chloroform administered to a Patient in 
labour. — Mr. Kay stated to the Liverpool Medical Society, (Feb. 3.) that he had 
tried chloroform in one case of midwifery requiring the application of the short 
forceps. The patient's convulsive movements were so violent, that he was obliged, 
to wait, until the effects of the chloroform had gone off, before he could apply them. 
— Ibid. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

66. Life Insurance. — In the America! Journal of Medical Sciences, N.S., Vol. XI. p. 
253, we stated the particulars of the case of Schwabe v. Clift, and the verdict of 
the jury. It would seem that this verdict has been set aside. The following ac- 
count is given in a recent Law Periodical. 

u A. effected a policy on his own life, subject amongst others to the following 
conditions: that the policy should become void, if the assured should die on the 
high seas, or should go beyond the limits of Europe, or enter the military or naval 
service, except with the permission of the assurers, and that ' every policy effected 
by a person on his own life should be void, if such person should commit suicide 
or die by duelling, or the hands of justice.' A. died in consequence of having 
voluntarily, and for the purpose of killing himself, taken sulphuric acid, but under 
circumstances tending to show that he was at the time of unsound mind. In an 
action by the administratrix of A., upon the policy, the defendants pleaded that A. 
committed suicide, whereby the policy became void, and at the trial, the judge 
directed the jury, that in order to find the issue for the defendants, it was neces- 
sary that the jury should be satisfied that A. died by his own voluntary act, being 
then able to distinguish between right and wrong, and to appreciate the nature 
and quality of the act that he was doing, so as to be a responsible moral agent; 
that the burden of proof, as to his dying by his own voluntary act, was on the de- 
fendants; but that being established, the jury must assume that he was of sane 
mind, and a responsible moral agent, unless the contrary should appear in evi- 
dence. Held, upon a bill of exceptions, that this direction was erroneous, for that 
the terms of the condition included all acts of voluntary self-destruction, and there- 
fore, if A. voluntary killed himself, it was immaterial whether he was, or was 
not, at the time, a responsible moral agent." — Law Magazine, No. 78. 

T. R. B. 

67. On the Existence of several Metals in the Human Blood. — Mr. E. Millon has 
addressed to the Academy of Sciences a memoir on the normal presence of many 



240 



Progress of the Medical Sciences. 



[July 



metals in the human blood, and an analysis of the fixed salts contained in that 
liquid. 

Upon receiving the blood issuing from a vein, in about three times its volume 
of water, and introducing it after this direction into a jar of gaseous chlorine, it is 
seen to coagulate, becomes of a brown colour, and soon after forms a gray amor- 
phous mass, in which the organization of the red particles entirely disappears.. 
When it is thrown upon a cloth and pressed, a liquid flows from it, which filters 
rapidly and remains liquid. 

If this reaction be minutely examined, we find a peculiar separation of the 
elements of the blood. The organic substances are found almost wholly in the 
coagulated portion, while, on the contrary, all the saline principles are collected in 
the liquid. This separation is so perfect, that when the coagulum is first washed 
and afterwards burnt, it is destroyed without leaving any residue. On the other 
hand, the liquid evaporated to dryness, and burned in the organic analysis tube, 
yields so little carbonic acid, that it cannot be estimated at more than one per 
cent, of the organic matters of the blood, which chlorine does not coagulate. 

It is easy to convince ourselves that the coagulum furnished by the organic 
principles does not contain the fixed salts of the blood, and does not condense 
them, but contains such a quantity only as is. proportional to the quantity of the 
water with which it is impregnated, so that if we weigh the water in which we 
received the blood, and weigh it again after mixture with the blood, we may act 
upon a known weight of filtered liquid, as upon a determinate quantity of the 
blood. This liquid accommodates itself so well to all analytic researches, both 
as to quantity and quality, that we can immediately discover the quantity of one 
or other of the fixed salts of the blood. To give some idea of this rapidity, two 
or three minutes are sufficient to obtain from the blood even the iron which it 
contains in a state of limpid solution, in which all the reactions of this metal are 
discoverable. 

This method is, in fact, an analysis of the fixed salts of the blood in the hurried 
way, and cannot fail to be advantageously applied to other tissues, and to other 
liquids of the animal economy, added to which, the most repulsive organic mat- 
ters are by the action of chlorine converted into common saline solutions. 

The facility of isolating the saline portion of the blood, leads to other results 
well worthy of notice. M. Millon states that he has proved that the blood of man 
constantly contains silex, manganese, lead and copper. The proportion of silex 
and of the metals is sufficient to prevent the necessity of any peculiar modification 
of the analysis. After evaporating to dryness the liquor left after the action of the 
chlorine, the residue is to be calcined for a short time, to get rid of the small quan- 
tity of organic matter, which the chlorine has not rendered insoluble. The inso- 
luble portion of the ashes is then to be treated as a mineral, in which we find silex, 
manganese, lead and copper. It is found that 100 parts of the insoluble residue 
of the ashes of the blood yields 

Silica from 1 to 3 parts 

Lead " 1 to 5 " 

Copper " 0-5 to 2 5 " 
Manganese " 10 to 24 " 

After this determination, so easily effected, it becomes a subject of curious in- 
quiry whether the copper and the lead are disseminated through the whole mass 
of the blood, or if, as happens with iron, they are confined to the red particles. 

Experience has left no doubt on this subject. One kilogramme of the clot, care- 
fully separated from the serum of many bleedings, yielded 0-083 gr. of lead and 
copper; one kilogramme of serum separated from the preceding clot, yielded only 
003 gr. of these two metals, and M. Millon thinks that these three millegrammes 
of lead and copper contained in the serum, ought undoubtedly to be attributed to 
the red globules, dissolved or suspended in the lymph. 

It appears then, that the copper and the lead are not diffused throughout the 
blood, but are fixed with the iron in the globules; and everything leads to the 
conclusion that they contribute, as it does, to organization and to life. Do they 
exert a decided influence on the health'? Does chlorosis exist on account of de- 
ficiency of copper, lead and manganese? or is there excess, the secret cause of 



1848.] 



Medical Jurisprudence and Toxicology. 



241 



any obscure and disordered affection'? Therapeutics ought to answer these ques- 
tions and enlighten us in its turn. Legal medicine will, on its part, perhaps draw 
up useful hints as to the permanent presence of these metallic poisons, and with 
respect to their enormous variations, even in the midst of life. — London, Edinburgh 
and Dublin Philosophical Magazine, from the Comptcs Rendus, Jan. 10. 1848. 

T. R. B. 

68. Progress of Putrefaction, §C. — When we consider that decomposition had 
proceeded with such rapidity after death, as to render premature interment neces- 
sary, it is highly improbable that, after a lapse of two years and four months, the 
corpse of Cromwell should have been in such a state of preservation, as to admit 
of its being suspended from the gallows in the manner described by the journals 
of the day. Orfila, who has bestowed much attention on the subject of decompo- 
sition, found that, in a majority of cases, bodies were reduced to skeletons, at the 
end of fourteen, fifteen, or at the utmost eighteen months, even when buried in 
coffins and wrapped in clothes, and thus when no unusual sign of putrefaction had 
appeared before interment. The greater the decomposition before interment, the 
more speedy would be the destruction of the soft parts and dissolution of the liga- 
ments. A body buried in a gravelly soil, such as that upon which Westminster 
Abbey stands, would, under ordinary circumstances, undergo changes more slowly 
than if placed in a damp and rich soil, but it may be doubted whether such a 
locality would much retard the dissolution of bodies, in w^hich the putrefactive 
process had set in immediately after death and made great progress. From in- 
quiries of the Clerk of the Works at the Abbey, we find it uncertain how long- 
bodies lie there without becoming skeletons, as only one has been seen for many 
years, and that had been buried about sixteen years — it was a perfect skeleton. 

On a trial that took place in Edinburgh some years ago, Dr. Barclay, the cele- 
brated anatomist, stated, that the longest time he ever knew, during which the 
features were recognizable, was a fortnight. — Cooper on the Disease and Death of 
Oliver Cromwell in Dublin Quarterly Journal of Medical Science, May 1848. 

T. R. B. 

69. On Transparent and Opake Arsenious Acid. By M. Bussy. — It is well known 
that arsenious acid exists in the different states above mentioned, and also that the 
transparent variety becomes opake ; it has been stated that the former is less soluble 
in water than the latter. By performing experiments to determine this point, M. 
Bussy has arrived at the following conclusions. 1. That the transparent acid, far 
from being less soluble than the opake, as stated by several chemists, is on the 
contrary, much more so : the difference is nearly as three to one, at the temperature 
of about 55° F.; thus a- litre of water which dissolves forty grammes of the trans- 
parent acid dissolves only twelve to thirteen grammes of the opake. 2. That the 
transparent acid dissolves much more rapidly than the opake. 3. That neither 
of these acids possesses a perfectly constant degree of solubility. 4. That the 
opake is converted into the transparent, by long-continued boiling in water; that 
is to say, it acquires the same degree of solubility as the transparent acid, which 
is such, that one hundred grammes of acid dissolve in a litre of water at 212°. 
5. That under the influence of water and a low temperature, the transparent is 
converted into the opake acid. 6. That the mixture of the two varieties of acid in 
the same solution explains the anomalies observed in the solubility of arsenious 
acid. 7. That division which facilitates the solution of the opake arsenious acid, 
without increasing its solubility, considerably diminishes that of the transparent 
acid, and to such an extent, that the latter reduced to fine powder and levigated, 
is not sensibly more soluble in the cold than the opake acid.; this effect undoubtedly 
results from a transformation which it undergoes, either at the moment of pulveriz- 
ing, or of its contact with water. 8. That the acid which has become opake by 
the slow transformation of the transparent, by the action of ammonia, and the acid 
crystallized in water, are similarly acted upon by water and appear to belong to 
the same variety. 9. That under the influence of dilute hydrochloric acid, the 
opake acid dissolves more slowly than the transparent; this circumstance, which 
modifies the nature of the products formed during solution, explains why the 
phenomena observed by M. Henry Rose during the crystallization of the trans- 



242 



Progress of the Medical Sciences. 



[July 



parent acid, are not in general so intense in the solution of the opake acid. 11. 
That the difference which has been observed in the action of the two arsenious ' 
acids, on the tincture of litmus is merely apparent. — {Journal de Chimie Medicale. 
Feb. 1848.) London. Edinburgh and Dublin Philosophical Magazine, May 1848. 

T. R. B. 

70. Test for Strychnine. — In 1843, M. Marchand described the remarkable and 
perfectly characteristic property, possessed by -strychnine of giving a magnificent 
blue colour, passing quickly to violet, and lastly to yellow, when triturated with 
peroxide of lead and a few drops of concentrated sulphuric acid, containing one- 
hundredth of its weight of nitric acid. Since the period above mentioned, several 
chemists have examined this reaction, and M. Herzog has proposed to omit the 
nitric acid as useless; another chemist proposes to substitute peroxide of manganese 
for peroxide of lead, and M. Otto prefers bichromate of potash to these oxides, 
which, according to him, gives rise to a much finer violet colour, and to a certain 
extent, this is certainly the case. 

M. Marchand proposes certain objections to these omissions and substitutions, 
and demonstrates that the reagents which he has proposed are the best suited to 
the purpose. 

First, the nitric acid added in the proportion of one-hundredth to the sulphuric 
acid, is not useless, as stated by M. Herzog, for by its influence, the series of colours 
is produced much more readily and sensibly than when it is omitted. M. Mar- 
chand states that he was aware that strychnine yielded a fine blue colour by the 
action of pure sulphuric acid and peroxide of lead only; but that it is impossible 
to perceive the red and yellow colours, which are readily perceptible in the con- 
ditions prescribed by him; and the author adds, that he never said or believed, as 
supposed by M. Herzog, that strychnine, when placed in the circumstances de- 
scribed, might serve as a reagent for nitric acid. 

As to the substitution of peroxide of manganese for that of lead, the author has 
only one objection to make, which is, that the salts of manganese sometimes 
possessing a red colour, there can be no certainty that the series of colours ob- 
tained belongs properly to the substance supposed to be strychnine, since one of 
the reagents employed may itself give rise to one of the colours indicated. 

The same is the case with the bichromate of potash recommended by Mr. Otto. 
This salt produces by its solution in sulphuric acid, a yellow or green colour, and 
it follows that the series of colours indicated by M. Marchand is diminished by 
at least one colour, and sometimes by two, the yellow and red, and consequently 
the reaction is far from being complete. 

The method of employing M. Marchand'*s process is that of triturating the 
strychnine with peroxide of lead and concentrated sulphuric acid containing one 
per cent, of nitric acid: by this process, the colours obtained are blue, becoming 
rapidly violet, then gradually red, and lastly, after some hours, it assumes a deli- 
cate yellow colour. — (Journal de Chimie Medicale, April, 1848.) London, Edin- 
burgh and Dublin Philosophical Ma gazine, May, 1848. T. E.. B. 

71. Proof of Poisoning. a A case involving a point of some interest as regards 
medical jurisprudence, occurred at the last Liverpool assizes. The facts were as 
follows: — 

" Elizabeth Johnson was charged with the wilful murder of her husband, by 
administering arsenic. The deceased, who, at the time of his death, was in the 
forty-second year of his age, was described as being a very healthy man, and, as 
one of the witnesses said, had never been known to suffer a day's illness in his 
life. After partaking of supper on the evening of Thursday, the 26th of Novem- 
ber, he was seized with vomiting, and complained of severe thirst and of pain in 
the bowels, together with heat in the throat. Having remained in a very weak 
condition for some days, he died on the 3d of December. On the 4th, the day- 
after his death, a post-mortem examination was made by a surgeon, who at the 
trial described the viscera as being generally healthy, and that the internal surface 
of the stomach was highly injected : the same appearances were presented through- 
out the alimentary canal; the lips were excoriated, the gullet and bladder much 
inflamed, and the lungs of an unusually red or scarlet colour. The surgeon stated 



1848.] 



Medical Jurisprudence and Toxicology. 



243 



that these appearances might arise from an irritant cause, but he had never met 
with them as the result of natural causes, and that arsenic would, in his opinion, 
produce such symptoms. The witness also stated that he thought arsenic was in 
the body. The other medical man, who attended the examination, upon subject- 
ing the intestines to Reinserts test, obtained a slight film on the copper, but so 
slight that he could not say what it was. 

" Thus, the medical evidence, up to this period, remained in a very unsatisfactory 
state. However, the body, after having lain for some period in the ground, was, 
in consequence of some facts that transpired in the interim, exhumed in the early 
part of March, when a large portion of the internal parts of the stomach and the 
heart, were submitted to Marsh's test. The result was a metallic deposit on a piece 
of cold porcelain, which was found to be discharged by the action of chloride of 
lime. By another process, a yellow precipitate was produced. 

" From these appearances, the medical men concluded, that there was arsenic in 
the body, but not sufficient to have caused death. According to the evidence of one 
gentleman, the matter tested did not amount to the one-thousandth part of a grain. 
It was proved, in evidence, first, that the prisoner purchased arsenic ; secondly, that 
she had been heard to express threats against her husband: thirdly, that both by 
Marsh's and Reinsch's tests, arsenic was found in the body. 

" Under these circumstances, we should not have been surprised had the jury 
returned a verdict against the prisoner, although the quantity of arsenic found 
might not have been sufficient to cause death, inasmuch as the deceased might 
have got rid of a portion of it by the violent vomiting which preceded his death. 
Much reliance, however, was placed upon the smallness of the quantity found, 
and in addition to this, the learned judge, in summing up, suggested that, as it is 
well known that arsenic was contained in many substances, and might be ex- 
tracted therfrom, there was a possibility that, during the interval between the first 
and second exhumation of the body, owing to the grave where the body was 
placed, containing a great deal of water, (as appeared in evidence.) the poison 
discovered might be attributable to this cause. 

- We confess we are inclined to think this a strange theory, and one approach- 
ing very near to the circumstances endeavored to be established in the case of 
Tawell, in which apple pies were suggested as the medium of arsenic (prussic 
acid?) and cause of death. In the principal case, however, to which we are al- 
luding, the suggestion was more successful, and the jury acquitted the prisoner." — 
The Jurist. May 1, 1847. 

The above article seems to have given offence, and accordingly in the succeed- 
ing number, (May 8th,) there is an attempt at an apology, with the following ad- 
ditional remarks. " It appears that, at the first examination of the body of the 
deceased, no arsenic was found, and the jury on the inquisition returned a verdict 
of natural death. On the second examination, however, a small portion of arsenic 
was detected, and the medical witnesses stated that it was impossible their ex- 
periments could have introduced it, because the zinc and other metals used by 
them, in making the test, were previously tested, and were found quite pure, and 
in addition, the water was pure distilled water. Then on summing up, the learned 
judge stated that, this being so, it was material for the prisoner that the attention 
of the jury should be called to the fact proved, viz.. that after interment, the body, 
from the wetness of the soil around, had become filled with water, which, not being 
pure distilled water, might reconcile the appearances at the first examination, when 
no arsenic was found, with those of the second, when slight indications appeared; 
but that, if large quantities of arsenic had been found on the second examination, 
the fact of the body having absorbed the water, ought not to be taken into their 
consideration." . T. R. B. 

72. Poisoning by Bichloride of Mercury. — Three cases are stated to have occurred 
at Guy's Hospital, during the year April 1846, to March 1847. 

The first case occurred in a man aged fifty. Probably about a drachm was 
taken, and with a suicidal intent. The symptoms were anxiety, Hvidity of coun- 
tenance, and prostration, violent vomiting and purging; the dejections consisting 
mostly of mucus tinged with blood; skin moist, and occasional cramps : soreness 
of the mouth and fauces; no pain in the abdomen. The remedies used were eggs 



244 



Progress of the Medical Sciences. 



[July 



and opium. The tongue became covered with a grayish-white crust, and rigors 
and convulsions came on before death The patient lived five days with these 
symptoms. All this time, there was total suppression of urine, and absence of 
salivation. The necroscopic examination showed all the organs to be compara- 
tively healthy except the colon and rectum, which were violently inflamed, and 
of a dark-chocolate colour, the mucous membrane in many places sloughing. 

Another occurred in a young woman, who attempted to swallow a cupfull of 
the solution of bichloride, but being resisted, only a sufficient portion entered to 
affect the mouth and fauces, and none was swallowed. These parts were white, 
swollen and sore. The sub-maxillary glands were enlarged, but there was no 
ptyalism. The action was purely local, and the patient speedily recovered. 

The third case of poisoning by corrosive sublimate, was a suicidal act in a wo- 
man. The exact quantity was not known, but it was stated, the greater part of 
two-pennyworth. Her symptoms were extreme prostration and restlessness; ab- 
sence of pain in the abdomen; violent vomiting and purging, with bloody stools; 
no salivation; urine naturally secreted; intense inflammation of the vulva. The 
patient lived eight days. The principal necroscopic appearances were in the large 
intestine, which was of a deep chocolate colour, with sloughing green patches of 
mucous membrane. The vulva, also, was in a sloughy state. — Guy's Hospital Re- 
ports, New Series, Vol. 5. T. R. B. 

73. Remarkable Case of Suicide, by Prof. Fenger, of Copenhagen. The patient 
fired a pistol, loaded with pretty large shot, into his mouth. There was consider- 
able laceration, but he went on very favourably for four days, when violent he- 
morrhage took place from the mouth and nose, which proved rapidly fatal. The 
post-mortem examination showed that a single shot had penetrated into the right 
sphenoidal sinus, and wounded the carotid on the side of the cella turcica. — • 
Monthly Journal of Medical Science, (Bennett's,) Feb. 1848. T. R. B. 

74. Appearance of the Areola as a Sign of Pregnancy. — -Dr. Simpson showed the 
Edinb. Obstetric Society a woman seven months gone with child, whose breasts 
gave no indication whatever of her pregnant state. The case was a peculiar one. 
There w T as no doubt of her being pregnant, as the fcetal heart could be distinctly 
heard; but at an earlier stage, great doubt had been thrown on the nature of the 
case, from the presence of several large fibrous tumours in the walls of the uterus. 
These had even given rise to the suspicion, on the part of the physician she had 
consulted, that the foetus was extra-uterine. She had been four years married, and 
was now pregnant for the first time. On examining both breasts, there is no ap- 
pearance whatever of a single enlarged gland on the areola, besides, the areola 
is not all tumid, and is scarcely darker than the surrounding skin. Dr. Simpson 
had caused a drawing to be made of this breast, which he contrasted with ano- 
ther, of the areola of a lady who had never been pregnant, but was suffering from 
great uterine irritation. In this last instance, the areola was turgid and of a dark- 
brown colour; the papilla? were numerous and much enlarged, and the superficial 
veins very large and prominent. He had observed the same appearance as in the 
last case, in other non-pregnant women. In one, the woman could never be preg- 
nant, as the uterus was malformed, and not more than an inch and a half in length. 
In another case, the marks were so distinct, that the late Dr. Hamilton, trusting 
mainly to them as undoubted indications of pregnancy, two or three years before, 
pronounced the lady to be pregnant, when the uterus was only enlarged by a mass 
of fibrous tumours. 

Dr. Kerr had under his care, a lady who is now four months gone in her third 
pregnancy. The areola is not at all discoloured, but the papillae are much enlarged 
and prominent.— I6ic2. ; March 1848. T. R. B. 

75. Simulated (Edema of the Left Arm.— A. woman, aged forty years, said to be 
from the Provinces, came expressly to Paris in order to be treated for a consider- 
able mdematous swelling of the whole of the left arm, a swelling which she at- 
tributed to a commencing elephantiasis, one of her sisters having, according to 
her statement, had a similar affection of the arm. She was received at La Cha- 
rite, in the wards of M. Cruveilhier. The limb was placed upon a piliow ; forming 



1848.] 



Miscellaneous. 



245 



an inclined plane from the axilla. An attentive examination of the arm, axilla, 
shoulder, and breast, led to the discovery of nothing that explained the singular 
and abnormal swelling. The inclined position caused no change in it for several 
days. Her general health was excellent. The swelling of the limb was more 
evident in the morning and during the day, and greater in the arm than in the 
forearm and hand. It did not, however, resemble an ordinary cedema; the pres- 
sure of the fingers left no depression, nor was the skin hard, doughy or otherwise 
diseased. Early one morning, the patient was surprised with a tight ligature, 
which she had placed during the night, round the upper part of the arm near the 
axilla, which had strangled the circulation. The following day, not having a 
cord to tie round the arm, she produced the same effect by pushing up the sleeve 
of her chemise, and twisting the edge of it strongly, so as to compress the limb. 
The deception could be easily perceived on carefully examining the superior part 
of the limb, where a circular mark was observed made by the ligature. — Ibid. } 
March 1848, from the Annates de Therapeutique. T. R. B. 



MISCELLANEOUS. 

76. The Influenza which prevailed in London in 1847-48. — Dr. Webster brought 
this subject under the notice of the Westminster Medical Society, not so much to 
describe the symptoms characterizing the existing epidemic, as to mention a few 
facts which appeared of interest respecting its very great prevalence and mortalhy. 
According to his own observations, almost all the cases were accompanied by re- 
markable prostration of strength, of a much more decided character than during 
the former epidemic influenza. The pulse was usually very feeble : the extremi- 
ties were often felt exceedingly cold, notwithstanding the mild temperature of the 
weather ; and the pectoral affection generally present, although sometimes appa- 
rently of an inflammatory nature, was seldom so in reality. The general type of 
the complaint was asthenic, as exhaustion, debility, and depression of the system 
were the marked features of this malady throughout all its stages. According to 
the Registrar-General's reports, the disease, although rather prevalent in London 
during last November, did not prove very fatal until early in December. The 
deaths, in the second and third week of the former month, were only four in each 
of those two periods: but in. that ending the 27th November, thirty-six deaths are 
reported from influenza. It was, however, during the first three weeks of Dec, 
that this epidemic malady proved most fatal, 842 deaths having then occurred in 
the metropolis, in a gross mortality of 6816; thus making the deaths from in- 
fluenza 12-35 per cent, of the whole. Of these, 421, or exactly one-half, occurred 
in persons above sixty years of age; whereas, less than one-fourth, or only 193 
individuals, under fifteen years of age, were carried off by this epidemic during 
the same period. Contrasted with the above results, the deaths from the same 
complaint during the first three weeks of the current month of January had been 
considerably less than half the number which took place in the first three weeks 
of December, being 331 in a gross mortality of 4420, or only 7*48 per cent, of the 
whole, instead of 12-35 per cent., as in the previous instance. It is also curious 
that, unlike the results observed in the early part of last December, the majority 
of deaths from influenza during the first three weeks of January had occurred in 
persons under fifteen years of age, their number being 128; whereas only 102 
individuals sixty years old and upwards died during the same period from this 
complaint. The gross mortality from all diseases has been much greater through- 
out the metropolitan districts during the present winter than for many years past, 
and even since the great plague, 12,483 deaths, or nearly double the ordinary- 
number, have occurred during seven weeks, of which 1315. or 10-53 per cent., 
were from influenza. The deaths reported as from influenza in the week ending 
January 15th, had, however, fallen to 102; whereas, during the week ending the 
11th of December last, the fatal cases from the same complaint had increased to 
372, or more than three times the subsequent amount. During the first three 
weeks of December, when the epidemic was most prevalent and fatal, the tem- 
perature of the weather was remarkably high for the season of the year, it being 



246 



Progress of the Medical Sciences. 



[July 



often 56° or even 57°, the mean temperature of the whole period being 47° Fahr. 
The atmosphere was also very moist. The wind continued constantly south-west 
or south, and generally blew strong, whilst during the week in which the mortality 
from influenza was greatest — viz., in the week ending the 11th of December — 
the wind was often very high, and even stormy. On the other hand, during the 
three weeks ending the 15th of January, when the frequency and severity of the 
epidemic had so much declined, the weather had become much less moist, or 
even dry, and was generally calm in comparison, whilst the prevailing winds 
were either easterly or northerly. The temperature of the air also ranged from 
seven to thirteen degrees under the average of the previous period", the mean 
height of the thermometer having indicated thirty-four during the first week, forty 
in the second, and thirty-six in the third. Speaking generally, Dr. Webster's own 
plan of treatment was almost always stimulating and tonic — the reverse of anti- 
phlogistic. The usual remedies he employed consisted of antimonial powder, 
with extract of conium or hyoscyamus. and small doses of ipecacuanha, to allay 
cough and bronchial irritation. Ammonia, senna, cascarilla, cusparia, with nitric 
acid and quinine, proved frequently most useful, particularly the latter remedy, 
towards the end of the attack. When aperients were required, the mildest were 
only admissible, such as castor oil, &c, and the strength should be supported by 
beef-tea, mutton-broth, arrow-root, light and nutritious diet, with wine, and even 
brandy, all liquids being given warm. The patient remained in bed, and the 
horizontal position was enjoined (by Dr. Webster), with warm applications to the 
extremities, when necessary ; and mustard poultices, or sometimes blisters, were 
applied, but the former remedy was generally preferable. Bleeding, or depletion 
in any form, according to all but universal consent, was considered improper, 
and, if ever employed, proved injurious: even tartarized antimony, so frequently 
useful in apparently similar complaints, at other seasons, he (Dr. Webster) found 
not only inferior to ipecacuanha, in the recent epidemic, but often inadmissible, 
from the depressing effects it produced upon the system. — London Medical Gazette, 
February, 1848. 

77. Re-Vaccinations in the Prussian Army in 1847.— The total number of men 
vaccinated was 43,264; the number of those who bore marks of a former vacci- 
nation in a decided manner, 34.264 ; ditto with the marks not very distinct, 6,405; 
ditto with the marks not visible at all, 2,927. The vaccine virus developed itself 
satisfactorily in 25,544 ; very irregularly in 7,425; and not at all in 10,627. The 
vaccinations which had yielded no results were repeated ; they acted in 2,718 ; and 
failed entirely in 8,952 eases. In consequence of the present vaccination, there 
were developed from one to five vaccine pustules upon 13,295; from six to ten 
upon 8,164; from eleven to twenty upon 5,767; from twenty-one to thirty upon 
1,036 of the men. Amongst those who were vaccinated in the year 1847, there 
was, within the same year, no case of varicella, none of actual small-pox, and 
one only of ckicken-pox. The lymph was obtained from vaccinated children or 
grown-up persons. It is remarkable that amongst those who were subjected to 
re -vaccination there were several who had had the small-pox before, yet upon 
whom Lhe vaccine matter produced the usual pustules.— Lancet, June 17 } 1848. 




247 



AMERICAN INTELLIGENCE. 

ORIGINAL COMMUNICATIONS. 



Case of Prolonged Gestation in which the date of the Conception was 
accurately ascertained. By R. H. McIlvain, M. D., Charlotte, N. C. 

The following case of gestation, prolonged to probably 298, certainly to 
293 days, occurred under the personal observation of the writer. The 
parties are of unexceptionable character, and the statement of the husband 
that no intercourse was had after the night of the 4th of July, may be im- 
plicitly relied on. 

Mrs. ■ , whose character is above suspicion, was visited on the 

evening of July 1st, 1847, by her husband, whose business had compelled 
him to reside for more than a year before in a distant state. The husband 
remained till the morning of the 6th of July, and then departed, and did 
not return for more than nine months. On the nights of the 1st, 2d, 3d, 
and 4th of July, there was sexual intercourse between the parties, but 
none on the night of the 5th or after. Shortly after Mrs. ■ con- 
sidered herself pregnant, and on the 23d of April, 1848, was delivered 
after an easy labour of a fine healthy female child, weighing nine pounds. 

Supposing impregnation to have occurred on the night of the first, as a 
consequence of the first coition, the duration of the pregnancy must have 
been 296 days, but if we suppose the last copulation to be the one from 
which the pregnancy resulted, the period of gestation was 293 days. 

This case is interesting, inasmuch as it furnishes conclusive evidence, 
that gestation may be prolonged to thirteen, if not sixteen, days beyond the 
usual period. 

The large size of the child — being a full pound and a half above the 
average weight of female children, is a circumstance in favour of its having 
been carried beyond the usual period. 

The mother had borne three children previously, none of which weighed 
over eight pounds. 

Charlotte, N. C, May 25, 1848. 

The Smart-weed as a Remedy for Mercurial Salivation and Aphthous 
Stomatitis. (Communicated in a Letter to the Editor.) By R. Wilcox, 
M. D., of Elmira, New York. 

I have frequently, during the past year, prescribed a decoction of the 
leaves of the herb, well known by all in this country, and familiarly deno- 
minated, smart weed, as a remedy in mercurial ptyalism, and also in that 
form of aphthous stomatitis, which occurs during lactation; and the degree 
of satisfaction I have felt while using it, has only been equalled by my 
surprise. 

The possibility that this plant might possess remedial powers for saliva- 
tion was suggested to my mind by the fact that farriers employed it 
with success to the cure of that disease of the salivary glands of the horse 
called slabbering; and being destitute so far as I then knew of any agent, 
which, if locally applied, would exert a decided curative effect, I resolved 



248 



American Intelligence. 



[July 



upon its trial the first opportunity. The opportunity soon presented itself. 
The remedy was used ; and I was agreeably surprised when I saw every 
distressing and unpleasant symptom removed m twenty-four hours. 

I have now employed it in about twenty cases of mild mercurial saliva- 
tion, and have uniformly procured the same prompt and complete relief. 
I have tried its use in two of the severer forms, attended with numerous 
and deep ulcerations; these cases were made much more comfortable, but 
not cured. The benefits I derived from it in salivation induced me to 
make trial of it in the follicular stomatitis of nurses, which appears to be 
endemial to the valley of the Chemung River. (At least it is of much 
more frequent occurrence here, than at any location with which I am ac- 
quainted.) Within the last three months, I have prescribed its use in ten 
cases, and without an exception, they have been speedily and entirely re- 
lieved. 

I am not prepared to state what can be accomplished with it in those 
cases of aphthous stomatitis connected with a tubercular state of the con- 
stitution, having yet had no such case; neither have I used it where the 
ulcerations were deep ; in such cases, other remedies will doubtless be more 
effective. I suggest the remedy to my medical brethren for further trial, 
and if it shall prove in their hands to be worthy the commendation I have 
given it, I shall ever feel myself abundantly rewarded. The manner in 
which I have used it, is to take about an ounce of the dried leaves and tops. 
Water, one pint, boil twenty minutes and strain. The mouth is washed 
with it every hour through the day. 

Elmira, N. Y., May 8th, 1848. 

Case of Wesley Pine, the murderer of Mrs. Russell. W. P. Gibbons, 
M. D., Poughkeepsie. — On the 19th of January, 1848, Wesley Pine shot 
Mrs. Russell, at her residence in Pleasant Valley. He was tried at the 
Oyer and Terminer of Dutchess county, Judge Barculo presiding — con- 
demned and sentenced. The execution took place on the 26th day of May, 
in one of the cells of the prison. He seemed to retain consciousness for 
about two minutes; his struggles continued for four minutes and a half, and 
at the expiration of half an hour he was cut down. 

This individual was about 36 years of age. According to his own ac- 
count, from the time that he was 15 or 16 he had occasionally been subject 
to melancholia, at which times he would take liquor ; a very small quantity 
of which would have a great effect upon him. 

At three different periods of his life he attempted to kill himself. His 
father committed suicide; and from the evidence elicited during the trial, 
it appears that other branches of the family had been subject to monomania. 
The prisoner's counsel made the defence on the ground of insanity. 

Port-mortem examination two hours after death, in presence of Drs. J. 
Barnes, R. A. Varick, H. H. Cochran, and E. Deyo. 

The following measurements of the head were taken, as recommended 
by Combe : 

Distance across the frontal and around the spin- 



ous process of the occipital bone, . . 21.6 inches. 
From occipital spine to individuality, . H " 
" occipital spine to ear, . . . 4 T \ " 
" ear to individuality, .... 4| " 
44 ear to firmness, . . . . 5f^ " 
" destructiveness to destructiveness, . 5^ « 



1848.] 



Original Communications, 



249 



From cautiousness to cautiousness, . : 5 inches. 
" ideality to ideality, .... 5 t 2 q " 

Expression of the countenance natural. Slight suggilations over the fore- 
head and lower part of the face. Pupils clear ; conjunctiva somewhat 
injected. Tongue and gums exsanguiated. 

Body warm; temp, of the abdomen 80°. Rigidity of the muscles of the 
legs and face. Colour of the body natural. Form well developed, muscular. 

Pressure of the knot a little to the left of the occipital tubercle; no dis- 
location of the neck. Slight fecal evacuation. In cutting the scalp, the 
posterior temporal view of the right side was divided, from which there was 
a free discharge of black fluid blood; with this exception little or no blood 
escaped from the incision. Skull thin. Superficial veins of the brain 
much engorged with dark and liquid blood. A number of small spongy 
excrescences were scattered over the surface of the pia mater of the right 
side. Adhesions of the membranes to each other and to the substance of 
the brain on each side of the longitudinal sinus, and upon the middle lobes 
of the cerebrum. At the points of adhesion with the brain were four or 
five firm, white, fibrinous deposits of the size of a sixpence. Around these 
as nuclei the pia mater was thickened, and infiltrated with serum, having 
the appearance of jelly, the whole occupying a space of about three inches 
square. Ventricles filled with serum. 

Weight of the entire brain, without the dura mater, 48.30 ounces. 
" of the cerebrum, .... 41.40 
" of the cerebellum, .... 6.90 " 

On slicing the brain, the centrum ovale was found to be softened; there 
were but few bloody points in the horizontal sections. Choroid plexus in- 
jected. Cerebellum softer than the centrum ovale. 

• The trunk was opened by an incision extending along the median line 
of the body, from which no blood escaped. Extensive adhesion between 
the costal and pulmonary pleura of the right side. Lungs filled with air, 
and the vessels engorged with dark fluid blood ; structure healthy; no liquid 
in the cavity of the chest. But little serum in the pericardium ; heart 
natural; cava? and right auricle filled with dark fluid blood; left side nearly 
or quite empty; no coagula in any of the cavities. 

Peritoneum and viscera of the abdomen healthy. The stomach contained 
about two fluidounces of chyme, and the duodenum and small intestines 
about twice as much chyle; the prisoner had eaten a full breakfast. Small 
patches of inflammation in the mucous membrane of the stomach. Weight 
of the liver, 5 pounds avoirdupois; gall-bladder full. Spleen much en- 
gorged; weight, 9 oz. 1 dr. Weight of the kidneys 12 oz. 6 dr. No froth, 
in the oesophagus or air tubes. No coagulated blood was observed in any 
part of the body. 

On Antiscorbutic Diet. — By Isaac G. Porter, M. D. (Extract from a 
letter to the Editor.) 

The idea advanced by Dr. Foltz, U. S. N., in his report on scurvy, (see 
No. of this Journ. for Jan. 1848,) that the antiscorbutic properties of the 
potato reside in its starch, struck me with much force. Little else enters 
into its composition, if we except water, some fibrous matter, and a little 
mucilage, or albumen. That its beneficial properties, therefore, are owing 
to this ingredient, seems a legitimate and natural conclusion ; a conclusion 
strengthened by his argument, drawn from an analysis of scorbutic blood. 



250 



American Intelligence. 



[July 



From intercourse with masters of ships engaged in the whale-fishery, I 
have long been acquainted with the reputed properties of the potato, in this 
respect, and recent conversations with them have confirmed me in the cor- 
rectness of the opinion. Not an individual among them but feels perfectly 
secure against the scurvy, so long as he has potatoes on board. But they 
must not be too old, as they dry up and become useless. Capt. McC. says : 
" At New Zealand I purchased a large supply of potatoes, but they were 
of the old crop, the time for digging new ones not having arrived yet, 
being near at hand. I proceeded to sea, and two months afterwards, 
with a plenty on board, the scurvy broke out, and I had nine men down 
with it. As I was about sailing for port on their account, I fell in with a 
French vessel, just from shore, with some potatoes of the new crop on 
board. I could obtain only about a bushel, but that was sufficient to cure 
every man, though their gums were swollen and black, their teeth just ready 
to fall out, and their limbs beginning to show dark spots." 

Their value is also shown in this journal, for Oct. 1847, p. 455. During the 
late famine in Ireland, scurvy became prevalent in certain localities, those 
suffering from it "having a sufficiency of bread — others, meat in addition, 
with sometimes wine or porter; but all had been deprived of potatoes for 
months." " Experience," the writer adds, " has long shown that a diet 
consisting solely of the potato, is capable of affording nourishment and of 
preserving the body in perfect health." Certain nations, it is w T ell known, 
subsist almost entirely on rice, arrow-root, and similar kinds of vegetable 
food. These are all of the starch class, and it may be that therein, as with 
the potato, resides their chief value. These articles, particularly arrow- 
root, may furnish a desirable substitute for starch, as this latter is rarely 
if ever used, in its separate state, as an article of diet, while the former is 
equally portable, and may be made into excellent puddings, with spices, 
and if eaten with sauce of lemon juice and sugar, may be highly palatable. 
It may be purchased in any quantity in the Islands of the Pacific and else- 
where, and often as low as two and three cents the pound, which is much 
cheaper than flour as an article of diet. The same is true of Tapioca, 
and other articles of the starch-class. 

Conversing, a few days since, with Capt. R., one of our oldest ship mas- 
ters in the whaling fleet, I mentioned to him the theory in relation to starch, 
as being the chief ingredient in the potato. His crew had suffered most 
severely from scurvy in his last voyage. I inquired if he had any arrow- 
root on board. "No," was his reply, " for I was disappointed in obtaining 
it at the island, as it is my custom to do, for puddings, &c." On my in- 
forming him that arrow-root was almost entirely a form of starch, after some 
reflections he said — " I cannot but think there is truth in the theory you 
have named, for on looking back, I find that during those voyages when I 
took most arrow-root on board, I had the least scurvy. Besides," he 
added, " I was perfectly well during this last voyage, while all were sick 
around me, and two men died ; and I know not to what to attribute it, un- 
less it be to a practice which I have followed for years, of having, while at 
sea, a bowl of arrow T -root gruel at my breakfast." 

If the benefit resulting from the use of starch be as has been suggested, 
it may be profitable to contrast its compositions and its powers, as regards 
supplying the wants of the animal system, with other articles of diet. 
Thompson, in his late "Researches on the Food of Animals," gives the 
following list of nutritive or nitrogenized, and calorifacient or respiratory 
proportionals in a few familiar articles. Starch has 1 proportional of the 



1848.] 



Original Communications, 



251 



former and 40 of the latter. Arrow-root 1 of the former to 26 of the latter. 
Rice 1 to 10. Potatoes 1 to 9. Wheat flour 1 to 8. Barley 1 to 7. Oat 
meal, 1 to 5. Beans, 1 to 2£. Milk 1 to 2. Are articles of diet antiscor- 
butic, just in proportion to the relative quantity of carbonaceous fuel they 
contain? Or does the antiscorbutic property reside in a due admixture of 
the two elements referred to, and which is found existing naturally in the 
potato ? These are questions which can only be solved by experience and 
observation, and the result of my inquiries has been contributed with the 
hope that it may tend, at least, to direct the attention of others to the sub- 
ject. 

Scurvy is much more prevalent at the present day, than is generally 
imagined, and will even be liable to occur in whaling and other voyages, 
requiring long absence at sea. Should experience confirm the foregoing- 
theory in relation to the starch-class, it will furnish a beautiful illustration 
of the wisdom and goodness of the Creator, in placing the remedy in the 
immediate neighbourhood of the disease, existing, as does the former, most 
abundantly on sea-coasts, and in the islands of the sea. The discovery, 
if such it shall prove, is simple, (but simplicity is the seal of truth,) and 
will confer infinite advantage on the interest of navigation, and the health 
and happiness of seamen. We cannot, however, expect that singly and 
alone it will prove a specific. Combined, as Dr. T. suggests, with lime juice, 
its powers will be increased, but there must also be the avoidance of other 
active causes of disease aside from ill suited diet; such as cold and mois- 
ture, ill ventilation, and want of cleanliness, mental depression, over-fatigue, 
and its contrary, want of exercise. 

I cannot close, without alluding to the strong testimony adduced by 
Capt. P. in favour of the sal. nitre and vinegar treatment. He had been 
eleven months at sea, with only one ton of potatoes, and a crew of about 
thirty men, when the scurvy appeared in its most appalling forms. All 
except the officers, (four or five in number,) were prostrate, so that not a 
man was able to go aloft, on the duties of the ship. One man had died, 
others were scarcely alive, when they fell in with an English ship, that 
furnished them with nitre, and the directions for using it. This mode of 
treatment, it is well known, was first suggested by Mr. Patterson, Surgeon 
R. N., in 1794. It was not, however, his directions which were followed 
on this occasion, but the mode proposed by Mr. Cameron, Surgeon R. N. 
See Cyc. Medicin., by Forbes, article Scorbutus ; also, Med. Chirurg. 
Rev., 1830, p. 483. In three days after commencing its use, one man, 
who was previously regardedas near his end, was able to go aloft; another 
died after a very few doses, being beyond remedy before the medicine was 
commenced — but the remainder of the crew speedily recovered, without 
going into port. Since that time, he has always taken it with him, in his 
voyages, and whenever, from the period he has been out at sea, and other 
circumstances, he fears the disease is about making its appearance, he 
commences the remedy in small doses, and thus far, his crew has always 
escaped. During the disastrous voyage alluded to above, after his nitre 
was exhausted,. he used nearly a keg of gunpowder with vinegar, the effects 
of which, he thinks, are rather more happy than those of the nitre. 

New London, June 20th, 1848. 

[The interesting facts furnished by our correspondent may be considered 
as confirmatory of the views of Dr. Garrod, whose important researches 
will be found at p. 200 et seq. of the present No. of this Journal. — Ed.] 



252 



American Intelligence. 



Kreosote in Erysipelas. By P. Fahxestock, M.D., of Pittsburgh 
(Extracted from a letter to the Editor.) 

Allow me to state that, during a practice of many years, I have been 
in the habit of using kreosote in erysipelas of the face, (as well as on all 
other parts of the body.) in both its simple and phlegmonous forms, con- 
fining my local treatment to this article alone. And such has been the 
success of this treatment, that I have as yet to witness a case which has 
not yielded to it. 

In every case of local erysipelas I immediately apply the purest kreosote 
with a camel's hair brush over the whole of the affected surface, extend- 
ing it some distance beyond the inflamed part, and at the same time ad- 
ministering a dose of chlor. hydrarg. followed by a sufficient portion of 
jalap to insure free catharsis. This, in the majority of cases, is all I find 
necessary. But when the mucous membrane of the mouth and fauces 
is also affected, I pencil those parts with a strong solution of the nit. ar- 
gent., say from Jss to 3i to ^i of distilled water. 

In the phlegmonous form it will be found necessary to repeat the appli- 
cation more frequently than in the simple, with the addition of a bread and 
water poultice, applied nearly cold and well sprinkled with water strongly 
impregnated with the kreosote, or a cloth, kept constantly wet with the 
solution, especially for the face. 

The kreosote when applied, should cause the parts to become white imme- 
diately. If this does not occur, it is not pure. Thus you will perceive 
that success depends upon having the best quality of oil. It is worthy of 
remark that the skin does not become in the least marked by the applica- 
tion, no matter how often it is applied. 

I was first induced to make a trial of this remedy, by a remark made by 
Dupuytren in a small pamphlet which fell into my hands, in which he 
supposed it might be a good remedy in this disease. 

The result of an extensive and exclusive use of this article in erysipelas, 
has induced me to place the most implicit confidence in it; and all I ask 
of the profession is a fair trial for it, confident that whoever once tries it, 
will abandon all other articles in its favour. 

P. FAHNESTOCK, M. D. 

Pittsburgh, June \st, 1848. 

Proceedings of the Third Meeting of the Association of Medical Superintendents of 
American Institutions for the Insane. 

The Association of Medical Superintendents of American Institutions for the 
Insane, commenced its third meeting, at the Astor House in the city of New York, 
on the 8th of May, 1848, the Vice President, William M. Awl, M. D. ; in the chair 
and Thomas S. Kirkbride, M. D., Secretary. 

Present — Dr. James Bates, of the Marine Insane Hospital at Augusta; Dr. An- 
drew McFarland, of the New Hampshire State Hospital at Concord: Dr. Wm. H. 
Rockwell, of the Vermont State Hospital at Brattleboro; Dr. Luther V. Bell, of the 
McLean Asylum for the Insane at Somerville, Mass.; Dr. C. H. Stedman, of the 
Boston Lunatic Asylum : Dr. N. Cutter, of the Private Institution at Pepperill, Mass • 
Dr. John S. Butler, of the Connecticut Retreat at Hartford ; Dr. Amariah Brigham, 
of the State Lunatic Asylum at Utica, N. Y.; Dr. Pliny Earle, of the Bloomingdale 
Asylum, N. Y. ; Dr. James Macdonald, of the Private Institution at Flushing, L. I.; 

Dr. Renney, of the Lunatic Asylum on BlackwelPs Island, N. Y. ; Dr. G. H. 

While, of the Hudson (private) Lunatic Asylum, N. Y. ; Dr. Horace A. Buttolph, 
of the New Jersey Lunatic Asylum at Trenton; Dr. Thomas S. Kirkbride. of the 
Pennsylvania Hospital for the Insane at Philadelphia; Dr. Joshua H. Worthington, 
of the Friends' Asylum at Frankford, Pa; Dr. N.C.Benedict, of the Blockley In- 
sane Asylum at Philadelphia; Dr. Fonerden, of the Maryland Hospital at Baltimore; 



1848.] Original Communications. 253 

Dr. Wm. M. Awl, of the Ohio Lunatic Asylum at Columbus; Dr. John M. Gait, of 
the Eastern Asylum of Virginia at Williamsburg: and Dr. John R. Allan, of the 
Kentucky Lunatic Asylum at Lexington. 

Dr. Samuel B. Woodward tendered his resignation of the Presidency of the 
Association, which was accepted, and Dr Wm. M. Awl was elected President in 
the place of Dr. Woodward, resigned; and Dr. A. Brigham, Vice President, in the 
place of Dr- Awl, elected ^resident. The following preamble and resolutions in 
reference to its late President, were unanimously adopted by the Association, viz : 

Whereas, Dr. Samuel B. Woodward, at the present meeting of this Association, 
has tendered his resignation as President thereof, 

Resolved, That whilst accepting this resignation, we cannot adjourn without de- 
claring our high sense of the services of Dr. Woodward as President of this body, 
and also our full appreciation of his ardent and useful exertions for so many years 
in behalf of the unfortunate insane. 

Resolved, That the Secretary of the Association be requested to transmit to Dr. 
Woodward a copy of this resolution. 

Agreeably to appointment, Dr. Brigham read an obituary notice of the late Dr. 
White, of the Hudson Lunatic Asylum and the first Vice President of this Associa- 
tion, which was directed to be entered upon the minutes. 

Dr. A. V. Williams and Dr. Benjamin Ogden, two of the visiting physicians of 
the Asylum on Blackwell's Island, were invited to attend the sittings of the Asso- 
ciation; and a resolution was adopted, authorizing each member to invite any 
person interested in its discussions. 

In conformity with a resolution, adopted at the last meeting of the Association, 
Drs. Brigham and Macdonald made written, and Drs. Earle, Rockwell, Bates, But- 
ler, Allan and Kirkbride, verbal reports on the subjects of post-mortem examina- 
tions and the pathology of insanity, which, after consideration, were referred to 
the standing Committee on these subjects. 

Dr. Kirkbride read a report from the committee on publication, which was ac- 
cepted, and the Association subsequently resolved, That the committee on publi- 
cation, appointed at the last meeting, be continued, and instructed to publish such 
of the reports and such parts of the reports made to this association, and such parts 
of its proceedings as they shall deem conducive to the public good. 

Elevations and ground plans of many of the institutions for the insane in the 
United States and Canada were laid upon the table, for examination by the 
members of the Association ; — also a great variety of carving and fancy work made 
by patients in the New York State Asylum, — and a number of ingenious buckles 
and other improved fixtures; intended to be employed on restraining apparatus, 
and sent to the Association by the maker, John D. Fisher, of Philadelphia. 

Written reports were made on the following subjects, and after full discussion 
accepted, and laid upon the table, subject to future disposition by the Association, 
viz. : — 

On the comparative value of the different kinds of labour for patients, and the 
best means of employment in winter, by Dr. Rockwell ; on the advantages and 
disadvantages of cottages for wealthy patients, adjacent to hospitals for the insane, 
by Dr. Kirkbride; on the relative value of the different kinds of fuel, for heating 
hospitals, by Dr. Bates; on the most economical mode of treating the insane of 
the poorer classes, by Dr. McFarland ; on reading, recreations and amusements 
for the insane, by Dr. Gait; on the comparative value of treatment in public insti- 
tutions and private practice, by Dr. White; and on the effects on the insane of 
the use of tobacco, by Dr. Cutter. 

Remarks on the diseases and causes of death among the insane, were also read 
by Dr. Macdonald-; on the statistics of insanity, by Dr. Earle ; and a series of cases 
of mania-k-potu, treated by the inhalation of ether, in the Boston City Hospital, 
by Dr. Stedman. 

Invitations were received and accepted, to visit the Bloomingdale Asylum, un- 
der the care of Dr. Earle, and the private Institution at Flushing, L. I., under the 
care of Dr. Macdonald; and both institutions were subsequently visited, and ex- 
amined with great satisfaction, and the thanks of the Association tendered to these 
gentlemen for their courtesy, attention, and bountiful hospitality. 

The Association also accepted an invitation to visit the Asylum on Blackwell's 
No. XXXI.— July, 1848. 17 



254 



American Intelligence. 



[July 



Island, and, after a thorough examination of the buildings and arrangements, 
unanimously adopted the following resolutions: — 

Resolutions respecting the Receptacle for Pauper-lunatics at Blackwell's Island. 

The "Association of Medical Superintendents of the American Institutions for 
the Insane," holding their third biennial meeting in this city, have availed them- 
selves of the kind invitation of the civil authorities superintending the receptacle 
for the pauper lunatics of this great metropolis, at BlackwelFs Island, to visit and 
examine the unfortunate class there resident, and the provision made for their 
care, their amelioration, and their recovery. 

It would be far more grateful to their feelings, could they leave this, as they do 
the other asylums for the insane, in this vicinity, which they have also examined, 
in silent but respectful regard at seeing great objects properly accomplished. In 
so doing, they would escape the unpleasant necessity of instituting painful criti- 
cisms in the face of personal civilities, and the hazard of being considered, by the 
unreflecting, as guilty of improper interference in the affairs of a community not 
their own. 

Devoted as most of them have been for many long years of their lives to the 
care and restoration of those deprived of reason ; familiar as many of them have 
been from personal examination, with the condition of this class of sufferers under 
the varying circumstances of the different communities of the old and new world; 
looking upon themselves, while citizens of widely separated states, yet common 
denizens of that republic of humanity that knows no state lines, they willingly 
venture all risk of being misunderstood and misrepresented, when they declare 
their conviction that the arrangements for the three or four hundred pauper luna- 
tics of this city are far in the rear of the age, of the standard of other regions equally 
advanced in civilization and refinement, of the imperative demands of common 
justice, humanity and respect due to the image of a common Father, however 
much disfigured and changed. 

They would, therefore, appeal to the authorities of this mighty and opulent me- 
tropolis of the western world, to sustain the honour of their leading position; to 
those who must feel that they and their children have no immunity against loss of 
property, of friends, and of reason ; to those who recognize the obligations imposed 
by their own elevation and success to protect the friendless and miserable, to in- 
terpose their determined resolution no longer to permit the Empire City to stand 
below the demands of the age, in the justice, humanity, yea, in the common de- 
cency, with which those guilty of no crime, but stricken by the hand of Provi- 
dence in the loss of reason, are treated. Suffer no longer, we implore you, those 
whose sensibilities are not extinguished, but may even be more intense, whose 
honest self-respect and pride of character are not always permanently obliterated, 
whose return to society and to usefulness is not elsewhere the rare exception, but 
the expected result; to be abandoned to the tender mercies of thieves and prosti- 
tutes, who are, to a considerable extent, the associates and keepers of this helpless 
charge, and clothed with all the delegated authority and influence which such a 
relation necessarily implies. 

This Association has neither the means nor disposition to inquire why the pau- 
per lunatics of this community should have been allowed to lapse into that 
depth of degradation and neglect, of which it would be difficult elsewhere to 
find a parallel. 

Enough is it for them to know that such is the fact, notwithstanding plans and 
designs for every modern architectural requirement, as well as curative and ame- 
liorating appliances, have been long in the hands, and subjected to the favourable 
criticism and comparison of those elsewhere charged with the same duties, and 
have been recognized as fully adequate to meet the exigency. 

They have examined the recent report of the medical visitors, and conclude 
with them fully in their conclusions, as to the necessity of an entire change in the 
system ; in the impossibility of doing all that justice, humanity, and a sound eco- 
nomy require for the insane, except at a cost of money sufficient to provide faithful, 
competent, respectable assistants or keepers, and adequate means of classification, 
inspection, labour, amusement, ventilation, and cleanliness. They believe a just 
economy requires the abandonment, or conversion to collateral uses merely, of 



1848.] 



Domestic Summary. 



255 



those miserable apologies for insane hospitals, known as the old and the new mad- 
houses; and that if the island is retained as a site for these institutions, the original 
design, fully satisfactory in its great outlines and principles, should at once be car- 
ried out to completion. 

The following preamble and resolution were adopted by the Association, viz: 

Whereas, in the selection of medical superintendents to American institutions 
for the insane, it is important to choose men with the highest qualifications, both 
as respects professional acquirements and moral endowments, therefore, 

Resolved, That any attempt, in any part of this country, to select such officers 
through political bias, be deprecated by this Association as a dangerous departure 
from that sound rule which should govern every appointing power, of seeking the 
best men, irresponsive of every other consideration. 

The following resolutions were also adopted during the different sessions of the 
Association : 

Resolved, That a committee be appointed to report to this Association, at its next 
meeting, the best terms for the classification and designations of the different 
forms of insanity, and also the best anatomical and pathological terms for the 
various parts of the brain, and a nomenclature of the diseases which prove fatal 
to the insane. 

Resolved, That a committee be appointed to suggest the best plan of calling the 
attention of physicians in general practice to the proper treatment of the insane at 
their homes, and especially to their treatment during the first period of their 
disease. 

Resolved, That the members of this Association be requested to prepare and 
present to a future meeting, a statistical analysis of all the cases of insanity which 
have been admitted into the different institutions under their care. 

Resolved, That all subjects heretofore referred to committees, and not reported 
on at this meeting of the Association, be continued in the hands of the present com- 
mittees for future action. 

Resolved, That a committee be appointed who shall, either before or after our 
adjournment, select subjects and appoint members to report on the same, in writ- 
ing, at the next meeting of the Association. 

Resolved, That previous to the future meetings of the Association the secretary 
be requested to invite the Boards of Trustees, managers, or official visitors of each 
insane asylum on this continent, to attend the sessions of this body. 

Resolved, That the thanks of this Association be tendered to Messrs. Coleman & 
Stetson, of the Astor House, for their very liberal provision for the meetings of the' 
Association, and for which, oh account of its benevolent objects, they have de- 
clined receiving compensation. 

Resolved, That the thanks of the Association be tendered to the officers for the . 
able manner in which they have performed the duties of their respective stations. 

Resolved, That the Secretary be instructed to furnish an abstract of the proceed- 
ings of the Association to the editor of the American Journal of Insanity, and to 
the editors of the various Medical Journals in the United States, for publication in 
their respective periodicals. 

The Association continued its sessions until the afternoon of the 12th of May, 
and then adjourned to meet in the city of Utica, N. Y., on the third Monday of 
May, 1849, at 10 o'clock, A. M. 

By order of the Association. 

THOMAS S. KIRKBRIDE, Secretary. 



DOMESTIC SUMMARY. 

Popliteal Aneurism successfully treated by Compression. — Dr. J. Knight, of New 
Haven, relates, in the Boston Med. and Surg. Journ. (May 10, 1848), the following 
case of popliteal aneurism, successfully treated by compression : — 

"On the 18th of October, 1847, I was consulted, at the request of Dr. D. A. 
Tyler, of this city, by Henry Johnson, a wood-sawyer, about 48 years old, for a 
tumour in the left ham — the left leg being the limb he uniformly stood upon whilst 



256 



American Intelligence. 



[July 



at his business. This tumour Dr. Tyler considered to be an aneurism of the pop- 
liteal artery. For several months he had suffered from pain in the limb, especially 
below the knee, which the patient thought was rheumatism; and about two months 
before, had discovered a small tumour in the ham, which pulsated from the be- 
ginning, and which, as well as the pain, had been gradually increasing. I found 
the tumour of such a size as to occupy the whole of the popliteal space, and to 
press strongly upon the tendons of the flexor muscles, particularly those upon the 
outside of the limb. The leg, below the knee, was very painful and largely cede- 
matous. All the symptoms of aneurism were so strongly marked as to leave no 
doubt concerning the nature of the affection. The action of the artery and the 
pulsation of the tumour were easily suppressed by very moderate pressure upon 
the femoral artery, either where it passes over the bone of the pubis or in the 
groin, or still lower down where it passes under the sartorius muscle. The patient 
was directed to lie in bed for a few days; and to relieve the severe pain he suf- 
fered, laudanum was administered in doses of 30 to 40 drops, and, when neces- 
sary, some of the common cathartics. By these means, employed for about a 
week, the oedema of the leg was cured, and the pain very much diminished; in- 
deed, while in bed he was free from pain. The tumour, however, was unchanged 
in site or character. 

" We now concluded to attempt a cure by pressure on the femoral artery above 
the tumour, upon the plan recently practised by Hutton, Bellingham and others. 
For this purpose we employed successively all the means which have been de- 
scribed — the hoop tourniquet, the calliper-shaped instrument, the common tourni- 
quet, guarding the limb against the pressure of the strap by encasing it in thick 
sole leather, and by a variety of other mechanical contrivances. There was no 
difficulty in controlling the artery, either diminishing its action or suppressing it, 
by any of the instruments employed. By whatever instruments, however, the 
pressure was made, however carefully it was guarded, whether continued upon 
one point only or shifted from one part of the artery to another, the pain in a short 
time became so severe that it could not be borne. There was no difference, in 
this respect, whether the limb was left uncovered or enveloped in a bandage from 
the toes upward. The pain was not in the part pressed upon by the instruments, 
but in the whole limb below, and was felt about equally in the thigh, especially 
the outside of it, and the leg below the knee. The pain usually began in 25 or 30 
minutes after the pressure was applied, and became intolerable in 15 or 20 minutes 
longer, so that it could not be continued in any instance longer than an hour. 
These efforts were continued at intervals for eight or ten days, and, as nothing had 
been gained by them, were abandoned. Others have met with the same difficulty, 
and have been compelled to apply a ligature to the artery. 

u Before resorting to this, I concluded, with the concurrence of Dr. Tyler, to try 
manual pressure upon the artery. To accomplish this, a sufficient number of 
assistants was procured from the members of the medical class, who cheerfully 
offered their services. They were divided into relays — two keeping up the pres- 
sure for four or five hours, relieving each other every half hour, and these suc- 
ceeded by two others, and so on. Sufficient pressure to suppress the pulsations of 
the tumour was found to be most easily made with the thumb or fingers, without 
a compress, upon the artery, as it passes over the os pubis; and the direction given 
to the assistants was to keep up this amount of pressure as nearly continuously as 
possible. This treatment was commenced at 3 P. M. No pain of consequence 
was produced by it for five or six hours : and then it was not severe, so that the 
patient was quieted by one-eighth of a grain of morphia once or twice repeated, 
and slept for the most part during the night. About eight hours after the pressure 
was applied, the temperature of the limb was diminished, and it appeared shrunken 
in size. At 11 o'clock next morning, 20 hours from the commencement of the 
treatment, upon removing pressure from the artery, the tumour had diminished 
very little, if at all, and pulsated about as strongly as ever, but the tibial arteries 
could not be felt. Probably the blood had ceased to enter them from the tumour 
during the night, in consequence of a coagulum forming in the artery where it 
left the aneurism. Upon examining the parts the next morning, about 40 hours 
from the commencement of the treatment, the tumour was found nearly one-third 
smaller in size, firm and unyielding on pressure, and entirely without pulsation. 



1848.] 



Domestic Summary. 



257 



All treatment was discontinued. The femoral artery pulsated with its usual 
strength in the groin, and distinctly as far as its passage through the tendon of the 
adductor muscles. Between this point and the tumour, it could not be felt. 
Several of the anastomosing arteries, especially one upon the inside of the limb, 
could be felt pulsating strongly and enlarged in size. 

11 From that time to this, a period of five months, no change has taken place in 
the limb, except that the tumour has gradually diminished in size so as now 
scarcely to be felt; and the leg, which at first was cold and weak, has nearly le- 
gained its natural temperature and strength. 

"The peculiarity of this case consists in the manner of making the pressure 
upon the artery, by the hands of assistants instead of mechanical contrivances; 
and in the very slight pain which the patient experienced from it. The advan- 
tages of this mode of making pressure are such, that I should at once resort to it, 
if, upon trial, pressure by instruments was found to occasion much pain. 

It is interesting to look back upon the improvement which has been made in 
the treatment of aneurism during the past one hundred years. It is but seventy 
years since the only treatment ordinarily adopted for an external aneurism, con- 
sisted in cutting into it, emptying it of its blood, and applying a ligature to the 
two ends of the artery. The danger of this operation, from inflammation and 
from secondary hemorrhage, was such that a large proportion of the patients died. 

" The first and greatest improvement, and that which has led to all the others, 
was the plan devised, not guessed at, but fairly reasoned out with great sagacity 
from well-known physiological and pathological laws, by Mr. Hunter, of placing 
a ligature upon the artery at a distance from the aneurismal tumour. The success 
of this mode of operating has been so great, that surgeons had almost ceased to 
look for any improvement on it. 

l: Upon this plan, however, the treatment by pressure is a great improvement. 
It is one so simple, so easily practised even by those not familiar with surgical 
operations, and, so far as it has been tried, so entirely free from danger, that it 
well deserves to be employed in all cases to which it is appropriate. The princi- 
pal objection to this plan, is the pain which it sometimes produces. This is 
mentioned in the cases which have been stated, as often severe, and, in some, 
intolerable. This objection is removed, if it should be found, that in other cases, 
as in the one which I have stated, manual, in the place of instrumental pressure, 
• is so easily borne. One case does not prove that it will be so, but it is sufficient; 
to encourage others to make trial of it. In some cases of aneurism, which are so 
near to the trunk of the body that pressure cannot be made upon the artery between 
it and the heart, it may perhaps be made upon the distal side of the tumour with 
success. If it is so situated that efficient pressure can be made upon the artery 
beyond the tumour and before any considerable branch is given off from it, coagu- 
lation of the blood will probably take place, and a cure be effected. 

" The treatment by pressure would seem, also, to be adapted to some cases of 
traumatic hemorrhage; those especially where a deeply-seated artery is divided 
at the bottom of a narrow wound, as in the palm of the hand or the sole of the 
foot. The trouble and anxiety which attend such cases, are familiar to every 
surgeon. In such cases, continuous pressure for a long time would probably not 
be necessary. It is a well-known fact, that arteries, when wounded, bleed m 
paroxysms at varying intervals, usually of several hours, and that obvious symp- 
toms precede the hemorrhage. These are, increased heat, pain, and throbbing of 
the arteries of the part wounded. If, when these symptoms appear, pressure is 
made upon the artery above, as upon the brachial artery when the wounded artery 
is in the hand, the period of increased action of the vessels of the part and of 
hemorrhage may pass by, when the pressure can be removed, to be renewed 
again with the reappeaiance of the symptoms, and continued thus at intervals 
until the wound in the artery is healed. I make this suggestion for those into 
whose hands a case of this kind may fall. The trouble to the surgeon, which 
attends this mode of treatment, is not to be taken into the account when me life 
of the patient is involved, or when he is to be saved from a severe surgical 
operation." 

False Aneurism with Obliteration, probably congenital, cf the Aorta. — A highly 
interesting pathological preparation exhibiting a false aneurism with obliteration 



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of the aorta, was communicated to the Philadelphia College of Physicians at their 
meeting on the 1st of February last, by Dr. West, with the following history, 
which we copy from the Transactions of the College. 

" I. G., an Italian by birth, and by occupation a cabinet-maker, aged 32 years ; 
5 feet 6 inches high ; remarkably muscular and athletic; with the superior half 
of his body more developed than the lower; was taken on the 9th of January last, 
at noon, with great pain and distress in the chest, in consequence of which, my 
attendance was demanded in great haste. 

u The attack, which was represented by the messenger as colic, had seized him 
suddenly, the pain being attended with great nervous agitation and distress. On 
my arrival, the patient was lying quite flat on his back in bed, complaining of 
great pain in the cardiac region, but without any marked difficulty of breathing, 
and with no particular disturbance of the circulation, so far as was discoverable 
by the pulse. His countenance indicated suffering, but it was not flushed nor 
darkly suffused. No physical exploration, unfortunately, was made, his attack 
being regarded as chiefly nervous in character, and induced, it was thought, by 
great bodily and mental fatigue, incident to the recent illness of his wife, who 
had been removed but a week before, as a patient into the Insane department of 
the Pennsylvania Hospital. During her illness and afterwards, I had had occasion 
to see the husband frequently, but had never heard him complain of anything; 
he appeared, on the contrary, to be in the enjoyment of robust health. 

"After his death, I learned that, on last New Year's Eve, he had been taken 
suddenly, whilst at a billiard room, with dyspncsa or orthopncea, of such severity 
as to require him to seek support with his hands upon the window-sill, where he 
might also enjoy a larger supply of fresh air. This attack lasted for several mi- 
nutes, but when it had passed over he was able to walk home without assistance. 
Agreeably to the views entertained of the nature of his affection, he was ordered 
to take portions of a mixture of Hoffman's anodyne, tinct. assafcetidae and cam- 
phor: to have sinapisms applied to the ankles, and to maintain perfect repose 
both of body and mind. 

11 At 10 P. M. I found him much relieved of his dyspnoea and general distress, 
but he still complained of pain about the heart. At this visit he was lying fiat on 
his left side in bed, and without any apparent embarrassment either of the respi- 
ration or circulation. His friends, considering him much better, had left him for 
the night. The next morning he arose as usual and took his breakfast; shortly 
after this he said to a friend who had called to see him, that he wished the Doctor 
could relieve him of 'this pain,' indicating, at the same time, its seat, by placing 
his hand over the heart. He had scarcely uttered these words when he suddenly 
fell on the floor and expired. 

" Autopsy — Seven hours after death. Muscular system everywhere much de- 
veloped; no congestion of the cutaneous surface. On exposing the interior of the 
chest, the pericardium, in its right half, was found deeply ecchymosed ; within 
this sac was effused a pint of blood, fluid and coagulated, in about equal propor- 
tions. On removing this blood, an aneurismal tumour of the aorta was discovered, 
extending from the origin of this vessel to the point at which the great vessels are 
given off from it. The large veins were all turgid with blood. The aneurism 
was both true and false in its character, being constituted by dilatation of the aorta 
in all its coats, and, also, by the expansion of its fibro-serous or pericardial invest- 
ment: this latter membrane was much thickened, but not otherwise changed in 
structure, having been detached from the whole surface of the vessel, throughout 
the extent already mentioned, viz., from its origin at the heart to the great vessels 
springing from its arch, forming in this way, the external or false aneurismal sac. 
This latter was capable of containing at least half a gill of blood. The pouch of 
the aorta, formed by its dilatation, would have lodged a small hen's egg. The 
external sac displayed, at the distance of an inch from the heart, an opening or 
slit, about six lines in extent, which gave issue, finally, to the blood into the 
general cavity of the pericardium. 

"The aorta was reduced, at the point of dilatation, to the thickness of parch- 
ment, but was in no other way changed in structure. This artery, in the whole 
space comprised by the origins of its great vessels, did not exceed in capacity the 
left carotid. Upon the superior semi-circumference of the aorta, and at the dis 
tance of an inch from its valves, which by the way were only two in number" 



1848.] 



Domestic Summary. 



259 



existed an irregular opening, of about ten lines in diameter, with torn, fringed 
edges. The point of rupture, for such was the character of this opening, bordered 
immediately upon the heart. No morbid deposit was found in the coats of the 
aorta, nor did they present, in the neighbourhood of the rupture, any other un- 
natural appearanceb than those of thinness and dilatation. These latter changes, 
it is presumed, were occasioned by the constant obstruction to the course of the 
blood, interposed by the peculiar condition of the aorta now to be described. 
This latter constituted the most interesting feature in the morbid anatomy of the 
case. On tracing the aorta beyond the origins of the great vessels, its cavity was 
found to be entirely obliterated, at a point immediately beyond or to the left of the 
ductus arteriosus, the remains of this latter vessel existing in the form of a liga- 
mentous-like cord. The aorta presented at the point of obliteration, a well-defined 
and regular contraction, which looked exactly as if it had been produced by a 
ligature thrown around the artery, the closure of its cavity being occasioned sim- 
ply by the approximation of its sides. No tumour or any other source of com- 
pression existed either at, or in the neighbourhood of, the stricture. Beyond this, 
the vessel immediately resumed very nearly its natural dimensions, and so con- 
tinued throughout its course. It gave origin, in its whole length, to the usual 
branches; the upper pair of intercostals coming off immediately below the 
stricture. 

u The blood, therefore, in order to reach these vessels, was obliged to take a 
very circuitous route, viz., from the aorta into the subclavians, thence, as will be 
seen, through the internal mammaries and epigastrics, to the external iliacs, and 
finally, from these latter it had to pass up the aorta towards the heart, thus reversing 
entirely the natural currents. The great power of the heart in propelling the blood 
is well illustrated by the present case. 

"The large vessels springing from the arch of the aorta were much enlarged in 
capacity, especially the subclavians, which, as already intimated, were chiefly 
instrumental, by means of the internal mammaries and other branches, in keeping 
up the circulation between the heart and lower parts of the body. All the sub- 
clavian branches were increased in number and capacity, and so also were the 
vessels from below, with which they freely inosculated. The heart was generally 
enlarged and its walls thickened, but in neither of these respects to any remarkable 
extent. The internal mammary arteries, which pursued their course along the 
thoracic parietes in a very tortuous manner, were fully as large as the external 
iliacs, and so were the epigastric arteries; these vessels, viz., the mammaries and 
epigastrics, as already stated, constituting the main channels for keeping up the 
connection of the circulation above and below the aortic stricture. 

"In regard to the obliteration of the aorta, the question at once arises, was it 
not, in all probability, congenital? Such, we believe, to have been the fact, since 
it can hardly be imagined that the walls of this vessel, at any time after birth, 
could have commenced and maintained the close approximation necessary to 
ensure entire occlusion, without the aid of some extrinsic compulsory force, and 
nothing of this kind was revealed by dissection. We leave to the surgeon to 
determine the value of such cases in its bearing upon the operation for tying the 
aorta. 

"Independently of its abnormal anatomy, the case is interesting in a pathologi- 
cal point of view, as exhibiting the want of relation between the morbid lesions 
found after death, and the rational symptoms exhibited by the patient during life. 

"The physical signs, had they been consulted, might have revealed the aneu- 
rismal character of the disease, though they could not possibly have instructed us 
how to avert the necessarily fatal result. During the last week of his life, the 
patient had been constantly under our notice, and yet within this period, he had 
never, we believe, complained of the slightest feeling of indisposition. The di- 
latation of the aorta, to a greater or less degree, had no doubt existed for a long 
period, probably from birth; but of this we cannot be certain. The period, how- 
ever, at which the blood found its way through the ruptured aorta into the external 
aneurismal sac, may be pretty satisfactorily conjectured, we think, by reference 
to the symptoms of the case. Was not the dissection of this fibro-serous covering 
of the aorta, by the gradual escape into it of the blood, the cause of the severe local 
pain in the chest felt by the patient within such circumscribed limits, and which, 
it will be recollected, was the prominent, indeed the only marked symptom? 



260 



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Such, we conceive, would be a natural consequence of the disruption of thisfibro- 
serous covering of the aorta, from its close attachment to the vessel. Owing, too, 
to the firmness of this connection, the formation of the external sac must have 
been very gradually accomplished, and unattended therefore, with any marked 
sensation on the part of the patient, until by its great distension it began to give 
rise at times to the pain complained of. The bursting of the external aneurismal 
sac was, of course, the immediate cause of the rapidly fatal result. 

" The annexed drawing presents a very faithful representation of the aneurism 
after its rupture, and the contraction and obliteration of the aorta. 7 ' 




a. Point of stricture of the aorta. d. Opening of external sac. 

b. Remains of ductus arteriosus. e. Seat of rupture of the aorta. 

c. External aneurismal sacs f. Aorta dilated. 

Case in which a Corpus Luteum in Process of Formation was found coinciding with 
Menstruation. (Charleston Medical Journal, Jan. 1848.)-— Dr. Myddleton Michel, 
in an interesting article u On the Dependence of Menstruation upon the Develop- 
ment and expulsion of Ova," relates the following case in which he found a corpus 
luteum in the process of formation, coinciding with menstruation. 

The subject of this case was a woman convicted of murder, and executed on 
the 10th of Sept., 1847. At the post-mortem examination which was conducted 
by Drs. Gaillard, De Saussure and Cain, Dr. Michel requested that the interna! 
organs of generation should be closely inspected. 

" Upon the removal of the uterus and its appendages,' 7 says Dr. M., " we re- 
marked that there was no perceptible increase of size in the parts, though evident 
signs of congestion were detected, particularly in the tubes. The mouth of the 
uterus was slightly opened, tumefied, and its orifice dripping with blood. A ver- 
tical incision being made through the organ, the internal surface was found coated 
with blood, though the congestion of its mucous lining membrane was particularly 
confined to the upper part, about the entrance of the tubes. The stroma of the 
ovary of the right side presented a number of vesicles working their way towards 
the surface, and on the surface one or more vesicles, in progress of development, 
containing a quantity of clear fluid which was ejected with much force as they 
were opened. In the ovary of the left side several others were also present, but 
on the anterior surface we discovered a ruptured Graafian vesicle ; whose orifice 



1848.] 



Domestic Summary. 



261 



was partially closed by a clot of blood. This was evidently the one which had 
j ast discharged its ovulum. But being unprovided with the proper instruments, 
by the mutual suggestion of Dr. Gaillard and myself, I look this rare specimen with 
me to examine it carefully. 

" I apprehend I can clearly establish, from the condition in which I found the 
vesicle, that Jane was not pregnant, and that menstruation had only begun a day 
or two. She was incarcerated some weeks previous to her execution, and her 
anxiety and suspense before she was apprehended, incline one to believe that 
her every thought must for some time have been directed to her approaching fate. 
But a better argument is furnished by the vesicle in question, for its rupture had 
positively just occurred, and here are the proofs: the opened vesicle was only 
partly closed by a clot of blood; the granular membrane surrounded this, even 
protruding through the opening. Under the microscope a fragment of this mem- 
brane exhibited its usual appearance of little hexagons arranged like mosaic 
work. I called the attention of Drs. R. Motte and Hunt to this membrane, who 
were present when I examined it. Cutting through the vesicle, I found its large 
cavity filled with the clotted blood which is the immediate cause of its rupture, 
and removing this coagulum, the inner tunic displayed great vascularity, its ves- 
sels ramifying over its surface like the artery on the retina. This membrane was 
not yet folding to constitute the corpus luteum. 

"To those acquainted with the subject, it will be plain that rupture had recently 
occurred, and consequently that the ovum had not long escaped. I therefore dili- 
gently searched for the egg, knowing that if discovered, this would be the only 
case of the kind recorded. I was not fortunate in the attempt; the egg was in the 
tubes, but these were so corrugated (a condition in which all the other organs of 
like structure participated as perhaps the result of strangulation), that it was im- 
possible to open them. The surface of the uterus was then carefully inspected 
with a strong lens, but nothing was discovered. The mucous membrane was 
not hypertrophied, neither were the uterine crypts nor glands visible as I have 
seen them during this period. I therefore conclude from this point, associated with 
the fact of the congestion being greatest at the entrance of the tubes, that menstru- 
ation had just commenced, and finally that this excitement commences in the 
ovaries, passes next to the tubes, and then encroaches upon the surface of the 
uterus. This last remark perhaps is worthy of notice, as I believe it has never 
been expressed." 

Fracture of the Neck of the Femur within the Capsule — bony union. — Dr. N. W. Con- 
dit relates in the New Jersey Medical Reporter (April 1848), a case of fracture of 
the neck of the femur occurring in a gentleman over 80 years of age. The acci- 
dent happened in May, and the patient died early in the following November. 
The following were the post-mortem appearances. 

" The muscles and all the structure about the cervix-femoris were more pale 
than usual, and scarcely gave out any blood upon being cut into. The capsular 
ligament was entire, giving no appearance of having been lacerated; its texture 
was somewhat thickened. The ligamentum-teres was in a state of vascularity, 
which gave it about the colour of the muscles around the joint, though it retained 
its wonted firmness and strength. The acetabulum was normal in appearance. 
The neck of the femur was shortened, and on opening the capsule the fracture was 
discovered wholly within it. The head of the bone had been broken across 
transversely, exactly at its point of union with the neck, and about two lines from 
the bony edge of the acetabulum. The ridge characteristic of the seat of fracture 
had been thrown out, and the re-union was firm for rather more than three-quar- 
ters of the circumference of the bone. The limb having been drawn up by the 
contraction of the muscles, a considerable angle was formed by the head and 
neck at their point of juncture, but they were as firmly united by osseous forma- 
tion as if they had never been separated. On the upper side, where the fractured 
edges were not in apposition, union was not yet complete, but ossification was 
going on upon all the broken surface, and had the patient lived a few months, 
would doubtless have been perfected. Could the state of the injured part have 
been by any means ascertained, and had not the condition of the ankle forbidden 
it, the patient, I think, might safely have walked ; there was sufficient firmness at 
the fracture for the limb to have contributed its share of support to the trunk. From 



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a fear lest some accident should befall the specimen in handling it. I left it with a 
mechanic to have the head protected by a covering of wire. He placed it for safe- 
keeping in a desk in his room, belonging to another man, who removing the desk 
in his absence, threw out the bone, supposing it to be of no value, and though 
diligent search was made, it was not recovered. I had the preparation in ray 
possession for two or three years, and during that time it was shown to many 
members of the profession, who expressed but one opinion, that it was a case in 
which a complete fracture entirely within the capsule was re-united by ossification." 

Spina Bifida Treated by Injection of the Tincture of Iodine. — Prof. D. Brainard 
relates (Illinois and Indiana Med. and Surg. Journ., Jan. 1848). a case of spina 
bifida treated with injection of tincture of iodine. The patient, a girl of 13 years 
of age, had a tumour at the top of the sacrum nine inches in circumference and 
about three in height, with thin walls. She had been paralytic in the lower mem- 
bers, but within three years had acquired a partial use of them. She was idiotic, 
and passed both the feces and urine without regard to place. From neglect of 
cleanliness, numerous ulcerations and large cicatrices had, from time to time, been 
formed upon the pelvis and thighs. 

Under these almost hopeless circumstances, Dr. B. determined to inject into the 
sac a solution of iodine, with a view of exciting inflammation and procuring ab- 
sorption. This was done on the 2d Dec. 1847, in the following manner: — A small 
puncture was made with the lancet on the sound skin about half an inch from the 
base of the tumour and a trochar of the size of a common knitting needle carried 
obliquely into the sac. Through the canula of this a solution of gr. j of hyd 
potass, with gr. ss of iodine in f ^i. of water, was thrown into the sac and the 
instrument withdrawn. A sharp pain followed, which soon subsided. Compresses 
and a bandage were applied to prevent the escape of the fluid, and the child was 
laid in bed. There succeeded redness, heat and tension of the tumour with ten- 
derness to the touch and some febrile symptoms, for which a cathartic was ad- 
ministered and evaporating lotions applied to the part. In the course of a week 
these symptoms subsided, and the tumour became soft, yielding, and diminished 
in size. Compression by means of a roller around the pelvis was then applied, 
and kept up with as great degree of force as could be borne, but the filthiness of 
the patient and her indocility prevented this from being applied with regularity. 
It was frequently removed for twelve hours or more at a time. Still it diminished, 
and on the 27th Dec. was about half its former size. 

" At this time a second injection was used of half the strength of the first. This 
produced but little heat or pain, and the compression was continued. On the 15th 
Jan. 1848, the fluid was so far absorbed as to render it easy to press it down 
almost to a level with the surrounding skin. A spring truss was then substituted, 
and at the present time the sac lies in wrinkles, the bony opening can be distinctly 
felt, and there is no increase of swelling when the pressure is removed. Recently 
there has been manifested a decided improvement in the intellect of the child ; the 
other difficulties remain the same ; but with the removal of the cause, the partial 
paralysis will doubtless gradually disappear. The retention of the natural evacua- 
tions must depend upon the development of the intelligence, and the gaining of a 
control over the voluntary muscles. In its present condition, this case shows that 
the injection of a solution of iodine, followed by suitable treatment, is capable of 
curing an ancient case of hydrorachitis, and (so far as a single case can be taken 
as a guide) with but little danger. Further experience will be required to deter- 
mine the strength and quantify of the medicine to be used, the frequency of the 
repetitions; in younger subjects than this, it is obvious that the dose employed 
should be not more than a fourth of that used at first in this case." 

This certainly will be considered by most surgeons an extremely hazardous 
proceeding, and in its extenuation Dr. B. says tl that a number of facts have, within 
the last few years, come under our observation, tending to show that serous mem- 
branes are, when filled with serum, much less disposed to inflammation than 
when in a healthy state. Experiments are required to show which among the 
astringent and stimulating fluids can be brought in contact with them with least 
clanger; meanwhile the safety with which solutions of iodine may be thrown into 
the large articulations, into the sac of a congenital hernia, and in some instances 
into the peritoneum, and in this case into the arachnoid membrane, will free us 



1848.] 



Domestic Summary. 



263 



from the charge of presumption in suggesting that it, or some other solution, may- 
be worthy of trial in those cases of hydrocephalus, ascites and hydrothorax, which 
are hopeless under ordinary treatment." 

Foreign Body in the Trachea — Tracheotomy — Cure. By Wm. Davidson, of Madi- 
son county, Ind. (Western Lancet, May, 1848.) — The subject of this case was a 
child four years of age, into whose trachea a grain of corn had slipped. When 
seen by Dr. Davidson, half an hour after the accident, the child presented the 
following symptoms: — "Distressing and prolonged paroxysms of cough, termi- 
nating in emesis, and resembling in character cynanche tracheitis; indeed, so 
much so, that, without the previous history of the case, they might, even by ex- 
perienced men, be readily mistaken for this disease; deep and laboured inspira- 
tion, with a purple countenance; the pulse slightly accelerated. Finding that the 
respiration became gradually easier, the periods of cough more distant from each 
other, and that the parents were much averse to an operation, it was resolved to 
allow the patient to rest, and, if possible, to obtain some sleep." During the 
night the patient slept for some hours, and the next day the symptoms were much 
ameliorated. The following day, however, every symptom became aggravated ; 
"the cough was constantly present; inspiration appears to be painful, and made 
with ijuch effort; countenance sunken, and of a leaden hue; the whole body 
bathed in a cold clammy perspiration. 

" For the first time a foreign substance could be distinctly heard, during respi- 
ration, to pass up and down the trachea. It now became abundantly manifest, that 
suffocation was impending, and that without a resort to tracheotomy, dissolution 
was not far off. Thirty drops of chloroform, poured on a handkerchief, and laid 
over the nose and mouth of the patient, produced in less than a minute an uncon- 
scious state. Dr. D. immediately commenced the operation by an incision, a line 
or two above the cricoid cartilage, and extending downwards, in front of the tra- 
chea, for about two inches. In consequence of considerable venous hemorrhage, 
though the trachea was soon exposed, a half hour elapsed before an opening was 
made into it. At the end of that time, hemorrhage having ceased, four rings of 
the windpipe were divided, when, upon the first expiration, attended by a cough, 
a large sized grain of maize, which already showed signs of germination, was 
immediately ejected with considerable force. 

"The edges of the wound were brought together by adhesive strips: and the 
child recovered without the appearance of any untoward symptoms. 

" During all this time the patient was more or less under the influence of chlo- 
roform, which, of course, was renewed from time to time, as symptoms of re- 
turning consciousness made themselves apparent." 

" Doubts," Dr D. remarks, " might suggest themselves to the minds of many ? 
as to the propriety of using chloroform in tracheotomy, from a dread that its seda- 
tive influence on the eighth pair w 7 ould be such as to prevent coughing — an act 
almost essential to the expulsion of a foreign body from the trachea. I confess 
that I participated in these fears, which the event proved to.be groundless ; and it 
was only at the solicitation of Drs. Holcombe and Hodges, that I was induced to 
give chloroform atrial. No one but he who has operated on the trachea, with 
and without the chloroform, can sufficiently appreciate the value of this agent in 
tracheotomy. Without chloroform, in addition to the struggles and resistance 
which the child offers in ordinary cases, there is superadded, from the loud cries, 
alternate elevation and withdrawal of the trachea to a considerable depth. All 
those inconveniences are avoided with its use, and the embarrassments to be 
encountered are only such as appertain to an operation in any other region of 
the body." 

Expulsion of two Foetuses of unequal size at the same time. (Charleston Med. Joum,, 
Jan., 1848.) — Dr. Elias Horlbeck relates the following interesting case, to which 
he was called on the 27th of June, 1847. 

The patient, a coloured woman, had passed two menstrual periods, and was sup- 
posed to be about two months advanced in pregnancy. After undue exertion, 
she was seized with the most profuse flooding, which was arrested by the use of 
appropriate measures ; and the woman made a rapid recovery. Dr. H. concluded 



264 



American Intelligence. 



[July 



that the product of conception had been lost, as he had never seen a case in 
which there was such profuse flooding where the foetus was preserved. 

The patient afterwards suffered from occasional small hemorrhages, until Dr. H. 
w 7 as again called to see her, Oct. 16th, three months and nineteen days after the 
first attack, with profuse flooding, which had commenced two days previously. 
She stated that she had increased in size and in the regular course ; had felt the 
movement of the child ; that her breasts and abdomen had enlarged with all the 
other symptoms of gestation. The os uteri was open, pains were occurring at 
regular intervals, and things had gone so far that Dr. H. administered ergot to 
hasten the discharge of the embryo; after the first dose a well grown fetus of be- 
tween five and six months was expelled, which, her mistress stated, palpitated 
some time after its birth. The flooding was now checked, and the placenta was 
in the course of the evening discharged. On dissection it exhibited the fol- 
lowing appearances. The placental mass was of considerable size, having a large 
ruptured sac on one side, lined with the amnion, from the centre of which sprung 
the umbilical cord. The maternal surface of the whole mass presented a fresh 
appearance, as if just separated from the uterus; on close examination, it could 
be divided into two unequal masses, connected with the smaller of which, was 
perceived a smaller fetus enveloped w T ith its usual coverings. The transparent 
amniotic covering containing a clear fluid, in which was floating a fetus some 
seven or eight lines in length. The sac being opened, the embryo was recognized 
sound, fresh and plump and life-like in its whole appearance, presumed from its 
development to be about six weeks old. The features of the face, such as the 
eyes, mouth and nose, were distinctly visible, its thoracic and abdominal members 
about two lines in length, its abdomen completely closed. The umbilical vesicle 
was distinctly visible and filled with fluid. The cord had no swellings or bulg- 
ings in its course, but was of the same size throughout. 

Abnormal Distribution of the Thyroid Arteries — Prof. James Blake describes in 
the St. Louis Med. and Surg. Journ. (June 1848), the following case of abnormal 
distribution of the thyroid arteries, which is interesting from the circumstance that 
in the subject in which it occurred, neither the operation of tracheotomy nor laryn- 
gotomy could have been performed without great danger of sacrificing the life of 
the individual. The subject in which it occurred, was a male about forty years 
of age, brought into the dissecting room of the St. Louis University, during the 
past session.- The first anomaly that presented itself on dissecting the arteries 
going to the head and neck, was that of a considerable artery about the size of a 
quill, arising from the anterior and superior of the innominata, passing upwards 
and crossing the trachea about three-quarters of an inch above the sternum. 
After proceeding about two lines beyond the mesial line, it again turned to the 
right and crossed the mesial line about a quarter of an inch before the isthmus of 
the thyroid body, and proceeded to divide into branches along its lower edge on 
the right side. 

On dissecting the superior thyroid arteries, it was found that the artery of the 
right side arose from the external carotid, at the place where it is generally found ; 
but here it was seen to be much larger than usual ; it proceeded downwards to the 
upper and outer angle of the thyroid body, but instead of dividing into its terminal 
branches, as it generally does, it turned forwards and to the left, running along 
the upper edge of the cricoid cartilage, or between it and the thyroid cartilage, 
and lying on the crico-thyroid muscle ; it continued this course until it passed 
rather beyond the mesial line, crossing the crico-thyroid ligament. During its 
course, it sent branches downwards to the upper edge of the right side of the thy- 
roid body, and the isthmus and its terminal branches were distributed to the left 
lobe of the thyroid body. The artery where it crossed the crico-thyroid ligament 
was as large as a crow-qnill; there was no large anastomotic branch uniting with 
the superior thyroid artery of the opposite side, which was rather smaller than 
natural. The inferior thyroid arteries were natural, but that of the right side 
rather larger. The thyroid body was rather above the natural size, and some- 
what more dense in its structure, and less red than it is generally found — the 
isthmus was broad, extending as far as the lower edge of the cricoid cartilage. 
From the above description it is evident that neither the operation of tracheotomy 
nor iaryngotorny could have been performed in this subject without incurring the 



1848.] 



Domestic Summary. 



265 



greatest risk of wounding an artery, the bleeding from which raight ; under the 
circumstances, even have led to a fatal result. 

Iodide of Potassium a Cure for Nurses' Sore Mouth. — Dr. H. D. Holt states (New 
York Journ. of Med., May 1848), that every case he has treated of this disease 
"has yielded within forty-eight hours to the use of iodide of potash in gr. v. doses 
three times a day.' 7 

Geranium Maculatum a cure for Mercurial Salivation. — Dr. Geo. M. Maclean has 
used in one case of mercurial salivation, he says, (New York Journ. Med., May 1848,) 
an infusion of the Geranium Maculatum as a lotion with speedy and entire relief. 

Case of Chronic Tetanus successfully treated by Ether Inhalation. — Dr. Isaac Parrish 
read to the Philadelphia College of Physicians, March 7th, (Trans. Coll., vol. ii. 
No. 4,) an interesting case of phlegmonous erysipelas, commencing in the finger 
and extending up the hand and arm. Rigidity of the jaws supervened on the 
sixth day, followed by shooting pains up the limb to the neck and jaws. The 
preparations of opium, assafoetida, &c, having failed to make any impression, the 
inhalation of ether was tried on the seventh day, and it produced a most favour- 
able anodyne effect, causing several hours refreshing sleep. The inhalation was 
repeated on the eighth day also with a favourable effect. Convalescence from 
this time was confirmed, and the patient recovered. 

American Medical Association. — A full abstract of the proceedings of the Asso- 
ciation, at its first annual meeting held in Baltimore in May last, having been 
given in the Medical News and Library for June, it is sufficient at present to state 
that the meeting was a most delightful one, that the deliberations were charac- 
terized by great harmony, and that the utmost zeal was manifested for the ad- 
vancement of the profession. The volume of Transactions, which is now in 
press, will soon be published, when we shall hasten to lay before our readers an 
account of the highly interesting reports and memoirs read to the Association. 

The following are the officers and standing committees for the present year: — 

President.— Dr. A. H. Stevens, of N. Y. 

Vice Presidents. — Drs. John C. Warren, Mass., Samuel Jackson, Pa., W. M. Awl ? 
Ohio, and Paul F. Eve, Ga. 

Secretaries. — Drs. Alfred Sfille, Pa., and H. I. Bowditch, Mass. 
Treasurer. — Dr. Isaac Hays, Pa. 

Committee of Arrangements. — Dr. Jacob Bigelow, Chairman. — Drs. E. Hale, Z. 
B. Adams, J. C. Dalton, John Ware, 0. W. Holmes, and H. I Bowditch, Boston. 

Committee on Medical Sciences. — Dr. L. P. Yandell, Ky., Chairman. — Drs. S. M. 
Smith, Columbus, 0., J. F. White, Cin., E. S. Carr, Vt., Samuel Jackson, (lale of 
Northumberland,) Pa., G. S. Upshur, Va , and S. H. Harris, Tenn. 

Committee on Practical Medicine. — Dr. D. F. Condie, Penn., Chairman. — Drs. W. 
W. Gerhard, Pa., M. Clymer, Philada., John Ware, Boston, Grafton Tyler, D. C, 
J. Fithian, N. J., and M. Z. Kreider, Ohio. 

Committee on Surgery. — Dr. N. R. Smith, Md., Chairman. — Drs. H. F. Askew, 
Del., W. H. Baxley, Bait., J. Knight, Conn., J. Pancoast, Phila., H. H. McGuire, 
Va., and A. B. Shipman, Ind. 

Committee on Obstetrics. — Dr. B. R. Welford, Va., Chairman. — Drs. J. F. Peebles, 
Va., Noble Young, D. C, Z. B. Adams, Mass., C. R. Gilman, N. Y., J. A. Eve, Ga., 
and R. Rouse, 111. 

Committee on Medical Literature. — Dr. J. P. Harrison, Ohio, Chairman. — Drs. G. 
Fries, Ohio, W. G. Edwards, 111., W. M. Latta, Ind., 0. W. Holmes, Mass., R. S. 
Stewart, Md., and J. M.Thomas, D. C. 

Committee on Medical Education. — Dr. F. Campbell Stewart, N. Y., Chairman. — 
Drs. John Watson, N. Y., J. M. Smith, N. Y., A. L. Pierson, Mass., S. H. Pen- 
nington, N. J., P. C. Gaillard, S. C, and D. Meeker, Ind. 

Committee on Publication. — Dr. I. Hays, Phila., Chairman. — Drs. A. Stille. Phila., 
H. I. Bowditch, Mass., D. F. Condie, Phila., J. R. W. Dunbar, Md., B. F. Barker, 
Conn., and J. Jump, Del. 

The next meeting of the Association will be held in Boston on the first Tuesday 
in May. 



266 American Intelligence. [July 



UNIVERSITY OF PENNSYLVANIA. 

At a Public Commencement held April 8th, 1848, in the Musical Fund Hall, Locust 
Street, the Degree of Doctor of Medicine was conferred by the Ret. Johit Ludlow, 
D.D., Provost, upon the following gentlemen; after which an Address was delivered 
by James B. Rogers, M. D., Professor of Chemistry. 



NAME. 




STATE. 


SUBJECT OF ESSAY. 


Abercrombie, Charles T. 


Russel, 


Ala., 


Cataract. 


Alexander, John B. 


Elbert, 


Ga., 


Dysmenorrhea. 


Anderson, James H. 


Talbot, 


Md., 


Different modes of dying. 


Barnett, A. W. 


Wilks, 


Ga., 


Inflammation. 


Barton, Howard T. 


Fredericksburgh, 


Va., 


Dysentery. 


Beale, C. William 


Orange, 


Va., 


Congestive Remittent Fever. 


Benton, John H. 


Jefferson j 


N. Y., 


Induction of Premature Labour. 


Berluchy, Samuel L. 


Adams, 


Pa., 


Vis Medicatrix Naturae. 


Bieber, Edwin H. 


Berks, 


Pa., 


Digestion, &c. 


Blanding, A. Ormsbee 


Bristol, 


Mass., 


Medical Topography. 


Brooks, Robert 


Stokes, 


N. C, 


Melaena. 


Brown, Samuel D. 
Bruce, George W. 


Kings, Nova Scotia, 


Digestion. 


Frederick, 
Philadelphia, 


Va., 
> 


Acute Rheumatism. 


Bryant, John D. 


Pa., 


Phthisis Pulmonalis. 


Buckman, Edwin D. 


Bucks, 


Pa . 

.ret., 


Dysentery. 


Burgess, John 
Burton, George W. 


Allegheny, 


Pa 


Animal Heat. 


Rutherford, 


Tenn., 


Cholera Infantum. 


Busey, Samuel C. 
Campbell, Edward M. 


Montgomery, 


Md., 


Cholera Infantum. 


Abingdon , 


Va., 


Circulation of Blood. 


Carter, Cassius 


Fai rfax, 
Philadelphia, 


Va., 


Remittent Fever. 


Chamberlain, George G. 


Pa., 


Puerperal Convulsions. 


Chandler, Chas. Quarles 


Louisa, 


Va. 


Duties of the Physician. 


Christian, Edmund 


New Kent, 


Va 


Dysentery. 


Claiborne, James W. 


Richmond, 


Va., 


Insanity. 


Clanton, S. W. 


Sninntpr 

O U 111 U CCI , 


Ala. 


Cynanche Trachealis. 


Coffey, Henry T. 


Blair, 


Pa 

ra. 


Importance of Cultivating Medi- 
cine as a Science. 


Comegys, Cornelius G. 


Kent, 

Philadelphia, 


Del., 


Hemorrhage. 


Cooper, C. Campbell 


Pa., 


Electricity the Nervous Force. 


Davis, Uriah Q. 


Union, 


Pa., 


Intermitting Fever. 


Davis, William H. 


Granville, 


N. C, 


Febris Intermittens. 


Dawson, John 


British Burmah, 


E. Ind., 


Theory of Cholera — Asiatica, 
Epidemica. 


De Jarnette, Joseph P. 


Antauga, 


Ala., 


Bilious Remittent Fever. 


De Jarnette, Joseph S. 


Spottsylvania, 


Va., 


Modus Operandi of Cold. 


Drake, Osborne L. 


Powhatan, 


Va., 


Urine, with its Pathological 
changes. 


Dungan, Jacob S. 
Duvali, Lloyd T. 


Philadelphia, 


Pa, 


Respiration. 


Frederick, 


Md, 


Dyspepsia. 


Duvall, Marius 


Annapolis, 


Md, 


Modus Operandi of Medicines. 


Edgeworth, S. Carpenter 


Houston, 


Ga, 


Congestive Fever. 


Edmunds, Benjamin C. 


Halifax, 


N. C, 


Asiatic Cholera. 


Ely, Edward 


Bucks, 


Pa, 


The Vital Functions, &c. 


Fairlamb, George A. 


Centre, 


Pa, 


Red Disc of Blood. 


Farley, George S. 


Montgomery, 


Ala, 


Pleuritis. 


Farrar, John 0. F. 


St. Louis, 


Mo, 


Dysmenorrhea. 


Farrar, John S. 


Howardsville, 


Va, 


Cynanche Trachealis. 


Fassitt, Louis 


Philadelphia, 


Pa, 


Theory and Art of Prescribing. 


Filbert, Charles K. 


Berks, 


Pa, 


Dysenteria. 


Forney, Jacob 


Huntingdon, 


Pa, 


Leucorrhoga. 


Gambel, William 


Philadelphia, 


Pa, 


Organic Forms or Species. 


Gayley, James F. 


Richmond, 


Va, 


Etiology of Intermittent and R.e- 
mittent Fever. 


Getty, Thomas Murray 


Elizabeth, 


Va, 


Colica Pictonum. 


Gibson, Henry C. 


Cooper, 


Mo, 


Bilious Remittent Fever. 


Gleaves, Samuel C. 


Buffalo Ford, 


Va, 


Colica Pictonum. 


Goodwyn, John P. 


Dinwiddie, 


Va, 


Circulation of the Blood. 


Gould, P. F. 


Nashville, 


Tenn, 


Congestive Fever. 



1848.] 



American Intelligence. 



267 



NAME. 

Green, Charles D. Jr. 

Grinnan, Andrew G. 
Gustine, John W. 
Hale, Elias W. 
Hall, George D. 
Halsey, R. S. 
Hamlet, John A. 
Haram, Samuel F. 
Harris, Charles M. B. 
Harvey, Richard II. 
Haskins, William D. 
Hawes, Ellington C. 
Heger, Anthony 
Heiskell, Milton Y. 
Hewson, D. C. 
Hey wood, Frederick 
Hobson, A. W. 

Hollinshead, Frank 
Hooper, William H. 
Horsley, Frederick Cabell 
Houston, James H. 
Huie, George William 
Hutchison, Ebenezer Nye 
Hutchison, Joseph C. 
Hyland, Christopher H. 
Jeffreys, Leonidas A. 
Jenkins, Foster J. 
Jones, Geo. Wymberley 
Jones, Walker F. 
Jones, W. A. 
Kelley, William D. 
Kennedy, Alfred L. 
King, John S. 
Kinloch, Robert A. 

Knighton, Nicholas S. 
Kollock, Cornelius 
Langhorne, Daniel A. 
Lemmon, Horatio S. 
Lemoine, Edwin S. 
Lewis, James S. 
Little, John Andrew 
Lukens, Isaiah 
Macklin, Benjamin R. 
Manly, L. Cheves 
Massie, William F. 
Mehaffey, William Kerr 
Moore, Thomas 
Mosley, William A. 
Mullen, John W. 
M'Cabe, John 
M'Kelvy, James B. 
M'Mackin, William C. 
M'Reynolds, H. W. 
Oliver, William W. 
Owen, John D. 
Pence, Philip 
Percivall, Charles-Fred. 
Person, Willie M. 
Pillow, N. B. 
Pollard, James R. 
Porter, Ransom N. 
Pulliam, John Junius 
Pumphrey, N. N. 
Purnell, Thomas H. 
Rhoads, Jacob 
Rives, Nathaniel F. 





STATE. 


SUBJECT OF ESSAY. 


Smyrna, 


Del., 


Reflex Function of the Spinal 




Cord. 


Fredericksburgh, 


Va., 


Dyspepsia. 


Juniata, 


Pa., 


Acute Enteritis. 


Mifflin, 


Pa., 


Pneumonia. 


Gaston, 


Ala., 


Uterine Hemorrhage. 


Dinwiddie, 


Va., 


Acute Rheumatism. 


Charlotte, 


Va., 


Cholera Infantum. 


Howard, 
Philadelphia, 


Mo., 


Typhoid Fever. 


Pa., 


Cynanche Trachealis. 


Gibson, 


Tenn., 


Pneumonia. 


Oakly, 


Va., 


Cause of Disorder in Pregnancy. 


Lincoln, 


Ga., 


Heat as a Vital Stimulus. 


Vienna, 


Austria, 


Ethyl. 


Morganton, 


Tenn., 


Intermittent Fever. 


New Orleans, 


La., 


Fistula in Ano. 


Worcester, 


Mass., 


Gonorrhoea. 


Clinton, 


Ala., 


Treatment of Bilious Remittent 
Fever. 


Stroudsburg, 


Pa., 


Cynanche Trachealis. 


Philadelphia, 


Pa., 


Carcinoma. 


Nelson, 


Va., 


Scrofula. 


Iredell, 


N. C., 


Gastro Enteritis. 


Louisville, 


Ky., 


Quantity of Blood in the Brain. 


Cabarrus, 


N. C, 


Physiology of the Encephalon. 


Cooper, 


Mo., 


Staphyloraphy. 


Princess Ann, 


Md., 


Bilious Remittent Fever. 


Wake, 


N. C, 


Febris Intermittens. 




Mass., 


New Anaesthetic Agents. 


Savannah, 


Ga., 


Endosmose. 


Gloucester, 


Va., 


Bilious Remittent Fever. 


Greensborough, 


Ala., 


Pulmonitis. 


Lebanon, 
Philadelphia, 


Tenn., 


Wounds of the Abdomen. 


Pa., 


Solubility of the Gases. 


Franklin, 


Pa., 


Haemoptysis. 


Charleston, 


S. C, 


Temperature, as concerned in 
the Causation of Disease. 


Anne Arundel, 


Md., 


Sulphate of Quinia. 


Cheraw, 
Campbell, 


S. C, 


Hemorrhagia Uterina. 


Va., 


Cynanche Trachealis. 


Fauquier, 


Va., 


Epidemic Typhoid Fever. 


Petersburgh, 


Va., 


Nourishment of Foetus. 


Orangeburg, 


S. C, 


Capillary Circulation. 


Delaware, 


Ohio, 


Cynanche Trachealis. 


Montgomery, 


Pa., 


Phrenitis. 


Brunswick City, 


Va., 


Hepatitis. 


Raleigh, 


N. C., 


Dyspepsia. 


Alexandria, 


Va., 


Intermittent Fevers. 


Marietta, 
Philadelphia, 


Pa., 


Treatment of Syphilis. 


Pa., 


Tetanus. 


Lincoln, 
Philadelphia, 


Ga., 


Physiology of Digestion. 


Pa., 


Pneumonia. 


New Castle, 


Del., 


Acute Hepatitis. 


Columbia, 
Philadelphia, 


Pa., 


Pneumonia. 


Pa., 


Acute Iritis. 


Columbia, 


Pa., 


Erysipelas. 


Madison, 


N. C, 


Scarlatina. 


Carthage, 


Tenn., 


Retention of Placenta. 


Pickaway, 


Ohio, 


Intermittent Fever of Pickaway. 


Frederick, 


Md., 


Ulmus Fulva. 


Franklin, 
Carthage, 


N. C, 


Scarlatina. 


Tenn., 


Pneumonia. 


Albemarle, 


Va., 


Prolapsus Uteri. 


Franklin, 


Mass., 


Treatment of Inflammation, 


Sommerville, 


Tenn., 


Cholera Infantum. 


Ohio, 


Va., 


Effects of Light. 


Benton, 


Mo., 


Hepatitis. 


Northumberland, 


Pa., 


Anatomy of Inguinal Hernia. 


Petersburgh, 


Va., 


Spina Bifida. 



268 



American Intelligence. 



NAME. 

Roberts, A. V. 
Robins, S. W. 
Robinson, A. L. 
Robinson, Francis 
Rochester, Thomas F. 

Roscoe, John T. 
Rose, John 
Rutherford, Levi 
Saunders, William H. 
Scollay, Charles L. 
Seip, Amos 



STATE. 

Scott, Miss., 
Wilcox, Ala., 
Boon, Mo., 
Annapolis, Nova Scotia, 
Rochester, N. Y., 



Bertie, 

Philadelphia, 

Dauphin, 

Washington, 

Jefferson, 

Northampton, 



N. C, 

Pa., 

Pa., 

D. C, 

Va., 

Pa., 



SUBJECT OF ESSAY. 

Physiology of Menstruation. 
Gonorrhoea. 
Typhoid Fever. 
Scrofula. 

Sulphuric Ether in Obstetric 

Practice. 
Hepatitis. 

Constitutional Peculiarities. 
Inguinal Hernia. 
Pneumonia. 

Inhalation of Sulphuric Ether. 
Peculiar form of Fever as it 
prevailed at the Glendon Iron 
Works, Northampton county. 



Seymour, "William P. 


Trnv 


1ST V 
IN. %: 9 


Scarlatina* 


Shannon, David P. 


Franklin, 


Pa 


Phthisis Pulmonalis. 


oneiion, jonn r>. 


Clarksville, 


Va 

v a., 


Displacement of the Uterus. 


Shippen, Edward 


Burlington, 


"NT T 


Angina. Pectoris. 


<5ill Frlwnrrl TV 

oiii, HiUWdiu jr. 


Richland, 

Pa mn}ip| 1 




Scarlatina.* 


OLIlllIJ, DUU&ci J? • 


va., 


"Prion m c\ n i a 

JT U C U LI 1 U 1 1 1 d. • 


Smith, George Hand 


Rochester, 


AT V 
JN. Y., 


Poisonous species of Rhus., in- 






habiting New York. 


in iii], joun a. r • 


JN ortnampton, 


AT C 


Fehris Intermittens. 


ismnn, ivino 


Hamilton, 


Tenn.j 


]VTarsh Miasma. 


Sorrel, Francis Jr. 


Chatham, 


via., 


Tetanus» 


Sfpvpncfvn Pharlpc T 1 


Bridgetown j 


Rai*KarlrkPC! 


x y uiiuo i cvcii 


Stewart, James L. 


Pittsburg, 


Pa., 


Labour Praematurans Artificialis. 


Stout, Samuel H. 


Davidson, 


Tenn., 


Medical Topography of Tenn. 


Stovall, S. B. 


Lincoln, 


Ga., 


Wounds of the Chest. 


Taylor, J. Marcellus 


Nash, 


N. C, 


Cornus Florida. 


Taylor, William T. 


Philadelphia, 


Pa., 


Food. 


Taylor, William V. 


Holly Springs, 


Miss., 


Dysentery. 


Thomas, William P. 


Columbia, 
Orangeburgh, 


Mo., 


Progress of Medicine. 


Thomson, Charles R. 
Towler, Joseph M. 


S. C, 


Marsh Miasma. 


Columbia, 


Tenn., 


Theory and Practice ofMedicine. 


Train, Arthur, 


Kenawha, 


Va., 


Acute Hepatitis. 


Trueheart, Fayette D. 


Henrico, 


Va., 


Intermittent Fever. 


Trugien, John W. H. 


Norfolk, 


Va., 


Human Eye. 


Vasser, George W. 


Monroe, 


Miss., 


Hepatitis. 


Wagner, Charles K. 


Easton, 


Pa., 


Cancer of the Stomach. 


Walke, J. Wistar 


Chesterfield, 


Va., 


Enteric, or Typhoid Fever. 


Ward, John 


Fauquier, 


Va., 


Physiology of Circulation. 


Webb, James 


Greene, 


Ala., 


Menstruation. 


Wellford, Armistead N. 
Wingfield, Charles L. 


Spottsylvania, 


Va., 


Application of Ether to Surgery. 


Albemarle, 


Va., 


Irritable Uterus. 


Wingfield, Thurmur H. 


Norfolk, 

Campbell, 

Philadelphia, 


Va., 


Acute Pleuritis. 


Withers, Edward D. 


Va., 


Morbus Brightii. 


Wright, W. Roderick 


Pa., 


Puerperal Fever. 


Workman, Edward E. 


Kershaw, 


S. C, 


Inflammation. 



The Degree of Doctor of Medicine was also conferred upon 

Dr. David Caldwell, Greensborough, North Carolina, 
" Alfred Wotkyns, Troy, New York, and 
" John W. Gloninger, Lebanon, Pennsylvania. 



At a Public Commencement held in July, 1847, the following gentlemen received the 
Degree of Doctor of Medicine. 



Brunson, Thaddeus W. 
Craig, James R. 
Davis, Ira S. 
Dunn, Samuel W. 
Jacoby, Leonard 
Miller, Nathaniel 

TOTAL, 174. 



Macon, 

Dinwiddie, 

Greene, 

Pennington, 

Bristol, 

Providence, 



STATE. 

Ala., 
Va., 
N. C, 
N. J., 
Pa., 
R. I., 



SUBJECT OF ESSAY. 

Colica Pictonurn. 
Inflammation. 
Tertian Intermittent. 
Asphyxia. 
Epilepsy. 
Diabetes Mellitus. 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR OCTOBER, 1848. 



CONTRIBUTORS TO THIS VOLUME. 



L. B. Anderson, M. D., of Elton, Hanover' City, Va. 

W. L. Atlee, M. D., Prof,